Board papers February 2015 by Surrey and Sussex Healthcare NHS Trust

Surrey and Sussex Healthcare NHS Trust Board Papers

February 2015

Trust Board Meeting – IN PUBLIC Thursday 26th February 2015 - 10:00 to 12:30 PGEC Room 7/8, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA 1

10:00

10:30

11:15

GENERAL BUSINESS 1.1

Welcome and apologies for absence

A McCarthy

Verbal

1.2

Declarations of Interests

A McCarthy

Verbal

1.3

Minutes of the last meeting held on 29th January 2015 - For approval

A McCarthy

Paper

1.4

Action tracker

A McCarthy

Verbal

1.5

Chairman’s Report For assurance

A McCarthy

Verbal

1.6

Chief Executive’s Report For assurance

M Wilson

Paper

1.7

Board Assurance Framework, & Significant Risk Register - For approval and assurance

G FrancisMusanu

Paper

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1

Patient’s Story For assurance

D Holden

Paper

2.2

Chief Nurse & Medical Director’s Report For assurance

D Holden/ F Allsop

Paper

2.3

Safety & Quality Committee Update For assurance

R Shaw

Paper

Winter Debrief – Presentation For Discussion & Assurance

P Bostock

Paper

Integrated Performance Report (M10) For assurance

P Bostock

Paper

OPERATIONAL PERFORMANCE 3.1

3.2

3.1

3.2.1

Operational & Quality Key Performance Indicators

D Holden/F Allsop

3.2.2

Workforce Key Performance Indicators

F Allsop

3.2.3

Finance Key Performance Indicators

P Simpson

Finance & Workforce Committee Update For assurance

R Durban

Paper

3.3

11:55

12:25

Nomination & Remuneration Committee Annual Report - For approval

A McCarthy

Paper

RISK, REGULATORY AND STRATEGY ITEMS 4.1

Care Quality Commission Action Plan Update For assurance

S Jenkins

Paper

4.2

Cost Improvement Plan Review 14/15 For approval

D Holden/P Simpson

Paper

4.3

Annual Plan Quarterly Progress Update For Assurance

S Jenkins

Paper

OTHER ITEMS 5.1

Minutes from Board Committees to receive & note 5.1.1

Finance and Workforce Committee

Paper

5.1.2

Safety & Quality Committee

Paper

5.2

ANY OTHER BUSINESS

5.3

QUESTIONS FROM THE PUBLIC Questions from members of the public may be submitted to the Chairman in advance of the meeting by emailing them to gillian.francis-musanu@sash.nhs.uk

5.4

All

DATE OF NEXT MEETING 26th March 2015 at 10.00am

A McCarthy

Minutes of Trust Board meeting held in Public Thursday 29th January 2015 from 10:00 to 12:00 Room 7/8, PGEC East Surrey Hospital Present (AM) Alan McCarthy (YR) Yvette Robbins (MW) Michael Wilson (PS) Paul Simpson (PBo) Paul Bostock (DH) Des Holden (FA) Fiona Allsop (PBi) Paul Biddle (PL) Pauline Lambert (RD) Richard Durban (RS) Richard Shaw (AH) Alan Hall

Chairman Deputy Chair Chief Executive Chief Finance Officer / Deputy Chief Executive Chief Operating Officer Medical Director Chief Nurse Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director

In Attendance (GFM) Gillian Francis-Musanu (SMB) Sacha Beeby 1.

Director of Corporate Affairs Notes

General Business 1.1

Welcome and Apologies for absence The Chairman opened the meeting by welcoming Trust Board members, staff and members of the public.

1.2

Declarations of Interest The Chairman asked if the Board members had any declarations of interest, none were recorded.

1.3

Minutes of the last meeting â&#x20AC;&#x201C; 18th December 2014 The minutes of the meeting held on the 18th December 2014 were approved as a true and accurate record.

1.4

Action Tracker The outstanding actions were completed and are now closed.

1.5

Chairmanâ&#x20AC;&#x2122;s Report for Assurance The Chairman took the opportunity to recognise the heroic efforts of staff throughout the Trust whilst activity pressures during the Christmas and New Year period placed great strain on clinical teams throughout the hospital and in particular our Emergency Department. The Macmillan Fundraising launch in January was very well attended with guest appearances from the President of the Olive Tree Charity and Newsreader Nicholas Owen. We hope that the momentum will be maintained in order to Page 1 of 13

achieve a fundraising target of £1.3m for the Macmillan Cancer Information Centre at East Surrey Hospital. Finally, CCGs are now recognising the impact that 4-day weekends (where Bank Holidays fall on either side of the weekend) have on hospitals and are being encouraged to better plan patient service provisions during the Christmas bank holiday weekend in 2015. The Chairman’s verbal update was duly noted by the Board. 1.6

Chief Executives report for Assurance The board received and noted the Chief Executive’s report in advance of the meeting. MW presented the report and highlighted the following; The Care Act 2014 will come into force from 1st April 2015. The Act sets out new duties for Local Authorities and partners and new rights for service users and carers. MW highlighted some of the key implications the Care Act will have on SaSH;  Eligibility criteria - an increase in the number of people requiring assessment.  Safeguarding will be on a legal footing, meaning that there will be a duty on all local authorities to undertake safeguarding enquiries.  A change to some of the paperwork and processes surrounding discharges from hospital which will require training and education for staff.  A responsibility to work with others to ensure that care needs are not prevented or delayed by taking a proactive and preventative approach to the physical, mental health and emotional wellbeing of people. This will include access to information and advice on services that are available. The Trust continues to work with social care colleagues and will play an active role in a system wide project Board to support the implications of the Care Act at SaSH. ACTION: The board will need to discuss the implications and impact of The Care Act in more detail during a Board Seminar. GFM In December 2014, leaders of the NHS in England published planning guidance for the NHS, setting out the steps to be taken during 2015/16 to start delivering the NHS Five Year Forward View. NHS England, Monitor, Trust Development Authority, Care Quality Commission, Public Health England and Health Education England came together to issue the joint guidance, establishing a firm foundation for longer term transformation of the NHS. The Trust is still awaiting further guidance and instruction from NHS England in respect of publication of revised National Tariff, standard contract for 2015/16. MW confirmed that the Trust had formally responded to the 2015/16 Tariff Consultation and awaits feedback from NHS England. It is likely that the published timetable for Commissioning Contracts will be delayed. MW announced the launch of the Mutual Pathfinder Programme which is being supported by Bolt Partners. The Trust will be exploring some of the benefits to staff and patients before undertaking a feasibility study of the programme. Page 2 of 13

On 14th January, the Trust hosted a Hot Topic event showcasing our Emergency Department. The ED team delivered a superb presentation to local community partners, GPs and CCG colleagues as well as local health partners and Foundation Trust members. There was great interest in the operations of A&E departments, the 111 non-emergency helpline and out-of-hours services. MW informed the Board that planned industrial action for 29th January and 25th February had been called off and the Trust awaits further feedback from this outcome. The report was duly noted by the board. 1.7

Board Assurance Framework and Significant Risk Register for Approval and Assurance GFM introduced the BAF and SRR for discussion and approval by the Board. GFM highlighted that the BAF now presents 19 risks, 5 of which are recorded as key strategic risks and red rated. The red risks continue to relate to finance and IT. Following review by the Executive Committee, the following recommendation was made for board discussion and approval; Risk 5B – it is recommended that the risk to ‘Clinical Leadership efforts not being embedded’ is reduced from 8, to 4 to reflect the current engagement and activity in leadership activities. The Board agreed. There have been no changes to the Significant Risk Register, which currently records 10 significant risks. The escalation of staff sickness levels within the Trust will be demonstrated in the next revision of the Significant Risk Register report – this was due to a timelag in reporting. AH challenged the current status of risk 4A in relation to the Recruitment & Retention strategy and whether it was appropriately scored as an Amber risk, recognising the growing levels of concern in this respect. FA confirmed that the current position should only worsen if the recruitment drive within the Philippines failed to deliver what we expect. PS further clarified the difference between risks; risks to services vs delivering level of services. YR challenged whether it might be appropriate to record an additional risk in relation to the cancellation of electives, noting an increasing backlog. PB provided some assurance that the number of cancelled operations throughout December had reduced, with increased day cases and further plans to improve delivery of the 18-week standard and further reduce the backlog. MW agreed that the cancellation of operations should be added to the Significant Risk Register as it directly affects patients. However, it must be clear that this is a national issue, with a national set of actions being managed by the Government. MW added that the TDA has instructed Trusts to significantly reduce their 18week elective backlogs during February, whilst accepting that the RTT standards Page 3 of 13

will be compromised during that time in order to treat those most critical patients. MW further recognised the efforts of clinical teams in continuing to deliver the expectations from quality standards throughout the Trust. DH highlighted the improved Infection Control management within the Trust which has seen a significantly reduced number of Norovirus outbreaks within ward areas. This period, we have seen only 2 ward closures, compared to 9 this time last year. PS clarified that the risk relating to commissioner contract negotiation was a business risk to the organisation if payment was not made and did not affect patients. PS agreed to ensure the appropriate level of risk is reported. The board approved the report. 2.

Safety, Quality and Patient Experience 2.1 A Patientâ&#x20AC;&#x2122;s Story The board received and noted the report in advance of the meeting. DH presented the report which provided an account of an elderly patient attending the Emergency Department with symptoms of dizziness in February 2014 during a visit from India. The patient was examined before a presumed diagnosis of Labrynthitis was made and the patient discharged with medication. Whilst in ED, the patient underwent a full chest X-Ray (CXR), although the investigation has failed to identify who requested the imaging. The CXR was reported after discharge and recommendations were made for the patient to return promptly for further imaging after suspected chest infection or cancer. Every effort was made to contact the patient by phone and by letter. The patient re-attended ED three months later with breathlessness and an obvious Bronchial Carcinoma. At that time, the patientâ&#x20AC;&#x2122;s son reported that his father did not register with a GP and that the dizziness and chest symptoms appeared to have gone â&#x20AC;&#x201C; he had therefore decided there was no need for further examination. The patient opted to return to India where he later died. This case was declared an SI in the first instance and investigated as such. However, the investigation showed that reasonable attempts had been made to try to ensure on going care for the patient. The two learning aspects around our processes include governance around the ordering of CXR imaging and being able to identify who has made the request and that the pathway for not picking up all Z5 reported CXR at MDT was not known in the ED. Electronic radiology requests should now resolve the first of these issues and a new critical results policy has been passed at the Clinical Effectiveness Committee. The department have reflected on the use of interpreter services to avoid overreliance on family members. This case was downgraded from a SI and removed from the national database as it was agreed that there had not been a lapse in care. PL acknowledged her assurance that everything reasonable was done to contact the patient. Page 4 of 13

DH added that it was very rare to receive GP patients with unsuspecting diagnosis. This patient was not registered with a GP and this may have contributed towards the patient not accepting appropriate care. DH further added that he felt reasonably assured that the functions of the MDT meetings were following best practice and Ed Cetti, as Clinical Chief for Cancer and Consultant Chest Physician has taken on the responsibility to ensure each MDT is fulfilling its role and responsibility. The board duly noted and took assurance from the report. 2.2

Chief Nurse and Medical Directorâ&#x20AC;&#x2122;s Report for Assurance The board received and noted the report in advance of the meeting. FA presented the first half of the report focusing on the safer staffing report and Sign up to Safety campaign. FA highlighted that the Trust score for total staffing compliance was 95.09%, with registered nursing compliance at 95.13% during the day and 97.39% at night. This provides assurance that our out-of-hours compliance is a priority to ensure safety. Sign up to Safety is a national campaign that was launched by the Secretary of State in June 2014. The campaign underpins the ambition set out of halving avoidable harm in the NHS over the next 3 years and saving 6000 lives as a result. NHS organisations who sign up to the campaign are expected to commit to 5 safety pledges; set out the actions they will undertake In response to the pledges; agree to publish this on their website for staff, paients and the public and commit to turn their actions into a safety improvement plan which will show how orgnaisations intend to save lives and reduce harm for patients over the next 3 years. Surrey & Sussex Healthcare NHS Trust has submitted its Safety Improvement Plan and has received feedback from NHS Litigation Authority regarding financial incentives. With its low claims record, the Trusts premium will reduce by ÂŁ290,000 in 2015/16 at a time when other Trusts are seeing an increase in premiums. The Trust will also have potential access to funding reserves to support initiatives in relation to Sign up to Safety. FA clarified that the safety pledges for which the Trust has signed up to supplement our own corporate initiatives and provides structure and discipline to demonstrate what we are doing. FA acknowledged the need to demonstrate clear, measurable outcomes and benefits against each of the pledges in order to monitor improvements as a result of actions implemented and changes made. FA paid thanks to Colin Pink for his efforts in relation to Sign up to Safety. DH presented the second half of the report focusing on feedback from a number of external events, the latest consultant appointments and developments in Electronic Prescribing. DH highlighted that a national safety drive for England had been launched by the Page 5 of 13

Department of Health, facilitated by the 5 AHSNâ&#x20AC;&#x2122;s. The programme for Kent, Surrey and Sussex will include work programmes in the areas of sepsis, pressure damage, falls, acute kidney injury and handover of care between secondary and primary community care providers. The national patient safety initiative serves as a well thought out programme which allows local collaboration with patients. It is funded and administered by KSS AHSN. DH summarised some of the key findings from the Virginia Mason study day hosted by the TDA in January. Virginia Mason Hospital in Seattle is famous for having achieved game changing gains in patient safety through standardisation of many processes by eliminating needless, valueless variation within teams. Senior teams from 15-20 non-FT trusts were invited to the seminar with a view to fund 5 improvement programmes with 5 providers. It is the intention that SaSH will apply to be one of the 5 providers working to implement the Virginia Mason model. DH highlighted that Dr Katy McGlone had successfully been appointed to the Trust as Consultant Paediatrician and will co-lead on safeguarding. Electronic Prescribing was introduced on Capel Annex during early December. Despite initial concerns for running the service during the Christmas and New Year period when medical cover was reduced, the project has run smoothly throughout and has increased to cover 15 beds on the ward. Informal feedback from the wards is very positive with a formal project evaluation due to take place in February, after which a decision on roll out across the orgnaisation will be made. DH further highlighted some of the positive developments from the recent KSS AHSN Expo and Awards ceremony and the newly formed weekly Patient Safety Executive presentation which has been very well attended by senior management and clinical teams across the organisation. An invitation was extended to Non-Executive Directors wishing to attend. These meetings take place every Wednesday morning at 9am and last approximately 20 minutes. The Chairman extended the Boardâ&#x20AC;&#x2122;s thanks to Colin Pink in relation to the Sign up to Safety programme of work and congratulated Dr Quraishi for the poster prize which rewarded his work on six steps to safety in sepsis. The Board duly noted and took assurance from the report. 2.3

Safety & Quality Committee Update for Assurance The board received and noted the report in advance of the meeting. The report summarised some of the key discussion points of the last committee meeting held on 8th January 2015. RS highlighted that the committee had received a presentation from Dr Ben Mearns, Consultant Physician on the stroke pathway which showed an improving trajectory and good audit compliance. The committee noted the improvement needed in getting access to a bed in the Stroke Unit within 4 hours. RS shared with the Board a letter from Crawley, Horsham and Mid Sussex CCG colleagues providing an update on the health systems-wide actions in response Page 6 of 13

to the CQC Quality Summit 2014. The letter outlined a number of developments underway in respect of the actions which the CCG are responsible for but does not appear to directly address the issues identified. The Trustâ&#x20AC;&#x2122;s response is being considered. RS further highlighted that the committee received a report setting out the timetable for the National Patient Survey programme in 2015. The committee will receive key findings from the surveys and will further share these with the Board. The board duly noted the report for assurance. 3.

Operational Performance 3.1.

Operational and Quality Key Performance Indicators The board received the Integrated Performance report in advance of the meeting. PBo updated the Board on the improving position in respect of cancellations. The Executive Committee hosted a debrief workshop inviting senior clinical teams to discuss lessons learnt from the Christmas and New Year bank holiday weekend and agree actions to mitigate some of the issues identified for future 4-day weekends. ACTION: A summary of discussions from the Executive Debrief following the Christmas and New Year bank holiday weekend, and the actions agreed will be shared with the Board in February. PBo Despite a challenging October, the month of December saw the organisation as one of the best performing Trusts in the Country. However, during the weekend period from 4-7th December, the Trust saw a peak in emergency admissions for patients over the age of 75. This was followed by a continued peak in medical take with the number of discharges not gaining the necessary momentum against the number of admissions. This resulted in escalation being opened. These continuing spikes in the medical take has contributed significantly to the medically-fit-for-discharge (MFFD) list with limited community service provisions for those patients and no capacity in the hospital to respond to any further spikes in activity. MW gave some further context that the Cabinet Committee are currently reviewing the MFFD lists of 26 hospitals where numbers exceed expectations. Agreement has been made with CCGs and the local authorities to reduce the list by 50% within the next 4 weeks. The Trust is currently negotiating when this will commence and the additional capacity needed across Kent, Surrey and Sussex to achieve this. MW added that the CCGs had accepted that greater investment in community services was needed. CHC assessments should not be undertaken in hospital and this position has not improved. The average length of stay for stroke patients was currently 17 days, against a national average of 4 days. Limited community provisions for stroke rehabilitation has not helped this position. PBo further highlighted that in December, 93.3% of patients were admitted or discharged within the ED standard of 4 hours with no 12 hour trolley wait breaches. The Trust did not achieve the ED 4 hour standard for quarter 3 with Page 7 of 13

performance of 94.4%. The Trust now faces extreme difficulties in achieving 97% performance delivery for quarter 4. All three aggregate RTT standards were achieved in December with a number of specialty failures as work is undertaken to reduce the number of patients waiting over 18 weeks for treatment. Aggregate RTT performance will not be achieved during February due to national plans to prioritise reduction of admitted backlogs. In December, ED achieved an Friends & Family Test (FFT) score of 93% and the inpatient score was 95%. The Trust continues to monitor ward nursing on a daily basis and is assured that adequate staffing is in place. RD gave further assurances from the Workforce Committee that the Trust was appropriately managing any impact on sickness absence. The committee undertook to better understand some of key themes of sickness absence which included stress, seasonal flu and staff morale. PS summarised that the Trust remains on plan at month 9 with a £1m surplus year to date. The risk to the forecast outturn is recorded as £6.3m potential adverse change. That risk is from income (emergency activity over plan and reduced elective) and divisional overspending. The financial impact of emergency and elective activity has been strongly felt across the country. The use of escalation has been costly to the Trust with a notable increase in agency nursing costs and outsourcing of elective work. Income from elective day cases and inpatients is now £1.5m adverse to plan. The year to date income continues to include an accrual in respect of challenge to CCGs over the level of emergency activity and the withheld marginal rate, as well as 2 tranches of winter resilience funding and the use of contingency from the balance sheet. There is a technical adjustment to the calculation of the accrual. The cost improvement plan year to date target is £7.4m and at month 9 this has been achieved. The forecast year end position remains a £2.3m surplus. Despite the level of pressures within the hospital, the Trust remains within forecast however, the effects of January may bring the Trust closer to the edge of its forecast. The underlying position at the end of December is £3m deficit, reflecting the nonrecurrent funding in the year to date position. The cash balance at the end of December was £4.9m, slightly above the planned position. The cash position will become more challenging as expenditure continues adverse to plan. Management of cash payments from CCGs has been proactive and it is hoped that payments by CCGs will be timely in future. The capital forecast spend adjusted to £19.3m – noting a reduction of £100,000 in respect of Salix funding and expenditure as agreed with the TDA. The Board duly noted and took assurance from the report. 3.2

Finance & Workforce Committee Update for Assurance The Board received and noted the update in advance of the meeting Page 8 of 13

RD highlighted some of the key points of discussion from the FWC meeting held on 27th January 2015. The committee received a paper in respect of Nursing Recruitment and Retention and verbal updates on the EPMA and EPR projects. RD added that a 15% turnover resulted in an annual recruitment target of 250 nurses which posed a significant recruitment challenge. The committee discussed actions to reduce turnover to the target of 12% or below. DH clarified that the EPMA roll out had benefitted a total of 15 beds, and not 15 patients. The committee received and approved an Outline Business Case to re-provide the Medical Records accommodation on the East Surrey site. The committee requested that certain aspects of the proposal were expanded upon in the Full Business Case. Month 9 reports were received for Finance, Workforce and Organisational Development, Capital and I.T. RD highlighted that the Trusts financial performance was discussed by the committee in great detail and summarised as described above. The Board duly noted the report. 3.3

Audit & Assurance Committee Chairâ&#x20AC;&#x2122;s Update for Assurance The Board received and noted the update in advance of the meeting PBi highlighted some of the key points of discussion from the AAC meeting held on 13th January 2015. The committee reviewed and accepted assessments of internal control linked to financial management and clinical governance. A draft annual report and a review of the corporate governance manual for the Trust was discussed and agreed for board submission. Internal Audit and counter fraud teams provided update reports which gave assurance on financial feeder systems, whilstleblowing systems and recent significant successful legal action taken by the Trust relating to time sheet fraud. PBi recognised that further thought was needed to consider the impact of significant changes in forecast planning in response to demand and capacity. PS agreed to consider this further and report back to the Board. PS further added that in recognising the pressures within the hospital, it is important that budget controllers are clear on what their budget is. It is the intention to formalise the CIP process and to be clear on those areas where the management of budget is at fault. The Board duly noted the report.

Page 9 of 13

3.4

Audit & Assurance Committee Annual Report for Assurance The Board received and noted the report in advance of the meeting. The report highlighted assurances of the committees activity, focusing on the development of the annual report, annual governance statement, review of internal and external assurances and controls and ongoing management of financial risk. PBi summarised that the Trust and its supporting Audit & Assurance committee was in good shape in terms of Internal Audit and the BAF review process was now well embedded within the organisation and providing sufficient assurance. It concludes that the Trust appears to be in good shape in preparation for Monitor due diligence. YR added that for future reports, it would be helpful to report specific areas where the committee has been assured, those areas less assured and what the committees response to those outcomes has been. The Board resolved to approve the Annual Report.

Risk, Regulatory and Strategy Items

4.1

CQC Action Plan Update for Assurance The Board received and noted the report and action plan in advance of the meeting. Sue Jenkins, Director of Strategy presented the CQC Action Plan which was developed following a visit by the Chief Inspector of Hospitals in May 2014 and in response to their findings in relation to service improvement. The board receives a monthly update on progress against the action plan. The CCGs have issued a response to the Trustâ&#x20AC;&#x2122;s Safety & Quality Committee Chair in respect of the system wide issues identified at the quality summit. MW echoed that the CCG response in respect of the system-wide actions identified by the Quality Summit failed to address the fundamental issues and were vague. AM challenged the role of the CQC and NHS in regulating delivery of what our partners are signing up to. The Board agreed that the Chairman should respond to the CCGâ&#x20AC;&#x2122;s letter of response outlining the expectations of the Trust in respect of the system-wide actions following the Quality Summit in 2014. Specific KPIs and timescale for completion should also be clarified. This letter should be copied to Cabinet Committee. ACTION: SJ agreed to draft letter of response to CCGs for sign off by the Deputy Chair (whilst the Chairman is on leave in February) in respect of Quality Summit system-wide actions. SJ announced that the new Outpatients Service Manager, Linda Judge has commenced post and minor refurbishment works within the existing department have been completed. Page 10 of 13

A trust wide review of demand and capacity data is currently being validated, whilst an electronic process for referrals is being developed and trialed with 2 GP practices. Lead Clinicians and members of the Outpatients team have met with a number of GP practices and CCG governance committees to consider views on referrals from a GP perspective. This is key to improving working relationships between the Trust and primary care. Patient focus groups completed, with feedback from this informing an action plan which is monitored by the monthly Outpatient Steering Group. A further focus group will be planned to engage staff views of Outpatient services at the Trust. The data supporting the number of cancelled clinics with less than 6 weeks notice is contributed to by morning clinics moving to the afternoon. PB further added that an expected increase in the number of ad-hoc clinics during February and March was positive and the Trust would welcome continued increase in the number of such clinics. ACTION: SJ to include update on â&#x20AC;&#x153;should doâ&#x20AC;? recommendations on a quarterly basis ACTION: SJ to include other system wide responses against actions agreed from quality summit in next report ACTION: SJ to present final report for Board sign-off of recommendations in March 2015. The Board duly noted and took assurance from the report. 4.2

Serious Incidents Report for Assurance The board received and noted the report in advance of the meeting. FA presented the report which highlighted serious incidents reported by the Trust during quarter 3 and provided an update on progress with known safety themes arising from serious incidents. ACTION: FA agreed to include a comparison of the number of Serious Incidents declared against the same quarter in the previous year for future reports. The Board acknowledged that the Trust was in a good position in relation to falls resulting in harm. FA further highlighted that the report should not be correlated with the current activity demands on the hospital. The Trust remains safe during peaks in activity. The report board duly noted and took assurance from the report.

4.3

Corporate Governance Manual Update for Approval The board received and noted the report in advance of the meeting. PS presented the report which presents amendments to the Corporate Governance Manual, Standing Orders and the Standing Financial Instructions and Scheme of Reservation and Delegation of Powers (SOâ&#x20AC;&#x2122;s & SFIs) as part of most recent review. Page 11 of 13

The main changes to the manual relate to the following areas:  Section A - Interpretation and definitions for Standing Orders and Standing Financial Instructions, and Section B - Standing Orders  Section C - Standing Financial Instructions: (significantly updated in July 2013 v2 therefore no major changes required)  Section D – Scheme of Reservation and Delegation  Section E - Codes of Accountability and Conduct & Openness for NHS Boards (no changes)  Section F – Anti-Fraud and Corruption  Section G – Tendering and Waiver Procedures: (significantly updated in July 2013 v2 therefore no major changes required) The manual is regularly updated and the final version will be uploaded onto the Trust website. The draft had been reviewed by the AAC. It was acknowledged that the detail of changes made throughout the report were unclear from the summary page; PS accepted this and agreed to improve the summary for the next submission, to ensure that the Board are clear on the comparison of the changes to the updated report. The board resolved to approve the report. 4.4

The Care Act 2014 – Safeguarding Regulations for Approval The board received and noted the report in advance of the meeting. FA presented the report which informed the Board of key changes to Adult Safeguarding which impact its services. A benchmark review was undertaken and an action plan resulted from this. The expectation is that the Trust will actively participate in Safeguarding Board meetings. FA highlighted that the Surrey Safeguarding Adults Board will become statutory in April 2015, brining duties and powers that have not previously existed in adult care. The Trust has a programme in place to revise its procedures and communications to reflect the new statutory duties. The Adult Safeguarding team have an Action Plan in place which will enable the Trust to be in a position to assure the Board that it will be fully compliant with the Act and its guidance by April 2015. Fiona Crimmins, Adults Safeguarding Manager will continue her role with the Trust and it is likely that a slight change in job title will be required. The Trust also has a process in place to sign off the Multi Agency Procedures that will have been revised by Social Care. PL acknowledged the robust framework for Safeguarding within the Trust and encouraged the Board to influence the alignment of processes with Surrey and with Sussex to ensure they work well for the orgnaisation. AM questioned what level of strain the Act would place upon the Trust. FA responded that beyond training, it is not expected to place additional financial strain upon the Trust in respect of resource. However, the Mental Capacity Act and DOLS Assessments will have a major impact on the Trust. The Care Act is likely to place greater impact on local authority Boards. The Board acknowledged that a greater understanding of legal and regulatory Page 12 of 13

impacts would be beneficial to ensure implementation. The Board resolved to agree the changes detailed within the report and approve the Care Act Action Plan 2014 â&#x20AC;&#x201C; Safeguarding Action Plan. 5.

Other Items 5.1 5.1.1

Minutes of Board Committees to receive and note Finance and Workforce

5.1.2

The minutes of the committee were noted with no questions raised. Safety & Quality Committees to receive and note

5.1.3

The minutes of the committee were noted with no questions raised. Audit & Assurance Committees to receive and note

5.2

The minutes of the committee were noted with no questions raised. Any Other Business MW informed the Board that FT Membership had increased with a new total of 8,609. This is a positive achievement for the Trust. No further business was discussed by the Board.

5.3

Questions from the Public There were no questions raised from members of the public.

5.4

Date of the next meeting Thursday 26th February 2015 at 10.00am in Room 7/8, Post Graduate Education Centre, East Surrey Hospital

Note: This is a public document and therefore will be placed into the public domain via the Trustâ&#x20AC;&#x2122;s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation.

These minutes were approved as a true and accurate record. Alan McCarthy Chairman:

Date:

Page 13 of 13

TRUST BOARD ACTION TRACKER Action Ref

Forum

Subject

Action

Date Open

Date Due

Date Closed

Status

Gillian F‐M

29.1.15

Paul B

29.1.15

26.2.15

OPEN

Sue J

29.1.15

26.2.15

OPEN

Sue J

29.1.15

ON‐GOING

OPEN

Sue J

29.1.15

26.3.15

OPEN

29.1.15

26.2.15

OPEN

29.1.15

OPEN

ACTIONS FROM LAST BOARD MEETING TBPU‐01

TB Public

Chief Executives Report

TBPU‐02

TB Public

Integrated Performance Report

TBPU‐03

TB Public

CQC Action Plan Update

TBPU‐04

TB Public

CQC Action Plan Update

TBPU‐05

TB Public

CQC Action Plan Update

TBPU‐06

TB Public

CQC Action Plan Update

TBPU‐07

TB Public

Serious Incidents Report

GFM to schedule Board Seminar discussion around implications and impact of the Care Act PB to share summary of discussion and actions from Executive debrief following Christmas & New Year bank holiday weekend SJ to draft letter of response to CCGs (on behalf of Chair/Deputy Chair) in relation to Quality Summit system‐wide actions SJ to include an update on "should do" recommendations on quarterly basis SJ to present final final board report for Board sign‐ off of recommendations in March 2015

SJ to include other system‐wide responses against actions agreed from Quality Summit in next report Sue J FA to include comparison of the number of SI's declared against the same quarter in previous years for future reports Fiona A

OPEN

TRUST BOARD IN PUBLIC

Date: 26th February 2015 Agenda Item: 1.6

REPORT TITLE:

CHIEF EXECUTIVE’S REPORT

EXECUTIVE SPONSOR:

Michael Wilson Chief Executive Gillian Francis-Musanu Director of Corporate Affairs

REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

N/A

Action Required: Approval ( )

Discussion (√)

Assurance (√)

Purpose of Report: To ensure the Board are aware of current and new requirements from a national and local perspective and to discuss any impact on the Trusts strategic direction. Summary of key issues National Issues:  Report on Freedom to Speak Up Review  House of Commons Health Committee Report - Complaints & Raising Concerns Local Issues:  Opening of Earlswood Centre  Foundation Trust Membership  Macmillan Fundraising Appeal for East Surrey Hospital Cancer Information Centre Recommendation: The Board is asked to note the report and consider any impacts on the trusts strategic direction. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact

Ensures the Board are aware of current and new requirements.

Financial impact

N/A

Patient Experience/Engagement

Highlights national requirements in place to improve patient experience. Identifies possible future strategic risks which the Board should consider Includes where relevant an update on the NHS Constitution and compliance with Equality Legislation

Risk & Performance Management NHS Constitution/Equality & Diversity/Communication Attachment: N/A

TRUST BOARD REPORT – 26th February 2015 CHIEF EXECUTIVE’S REPORT 1.

National Issues

1.1

Report on Freedom to Speak Up Review

On 12th February Sir Robert Francis published his report on the Freedom to Speak Up review. In his report Sir Robert sets out a number of Principles and Actions which aim to create the right conditions for NHS staff to speak up, share what works right across the NHS and get all organisations up to the standard of the best and provide redress when things go wrong in future. The report also details good practice that is taking place and also reveals how some staff have not been treated as we would want and expect. To address the gap and variation, the report identifies ways in which organisations can create the right culture, how concerns should be handled and what is needed to make the system work. Included in the report are two over-arching recommendations, 20 principles and 36 specific actions that cover local and national organisations which are grouped under five key themes. These are the need for culture change, improved handling of cases, measures to support good practice, particular measures for vulnerable groups and extending the legal protection. The focus of the whole package is ensuring issues are dealt with as patient safety issues. With many of the local actions, there is a parallel recommendation to system regulators about how they assess this against whether an organisation is well-led. The two over-arching recommendations are: 1.

All organisations should implement the principles and actions in the report in line with the good practice outlined.

The Health Secretary reviews progress at least once a year against the actions in the report.

Some of the specific actions task boards locally with the need to: 

assess progress in creating and maintaining a culture of safety and learning, ensuring the culture is free from bullying



encourage reflective practice, individually and in teams, as part of everyday practice



have a policy and procedure built on good practice



talk about and publicly celebrate the raising of concerns



ensure staff have formal and informal access to senior leaders. In this area, it also recommends:



a person is appointed locally by the chief executive to act as a 'Freedom to speak up guardian'



an executive director and non-executive director are nominated as individuals within your organisation who can receive concerns



a manager in each department to be nominated to receive concerns



staff have access to advice and support from an external organisation (e.g., whistleblowing helpline).

The report also suggests the creation of an Independent National Officer. It is to be jointly resourced by the regulators and national bodies to be a support to the local guardians, advise organisations where good practice has not been followed and review the handling of cases when required. It also asks Health Education England and NHS England to develop a training package and tasks each organisation with ensuring that every member of staff receives training in how you expect them to both raise and act upon concerns. A letter has been sent to every NHS trust Chair and Chief Executive to re-enforce the importance of staff being able to discuss concerns openly in teams and for action to be taken. This letter has been circulated to all Senior Leaders in the Trust. The government has accepted in principle all of Sir Robert’s recommendations, including proposed new legislation to protect whistleblowers who are applying for NHS jobs from discrimination by prospective employers. The government will also shortly consult on other measures including:    

a new National Whistleblowing Guardian to protect those who speak up practical help through Monitor, the Trust Development Authority and NHS England to help whistleblowers find alternative employment a local whistleblowing guardian in every NHS organisation - reporting directly to the chief executive training for staff on how to raise concerns and protect others who do so

The final decision on how the recommendations are implemented will be made following consultation. These are important recommendations for the Trust and our plans to address the recommendations will be reviewed by the Executive Committee and the Finance and Workforce Committee and an action plan developed and implemented. The full report can be accessed here: Freedom to Speak Up Review.

1.2

House of Commons Health Committee Report Complaints & Raising Concerns

The report, Complaints and Raising Concerns published by the Health Select Committee on 21st January 2015, provides a follow-up review of the handling of complaints and concerns in the NHS since the Committee’s initial inquiry in 2011 into Complaints and Litigation. The latter examined the working of the NHS complaints system, including the

treatment of staff that raised concerns about NHS services, and the procedures in place to encourage NHS staff to raise concerns without fear of detriment. This report examines progress in implementing the relevant recommendations made in the Committee’s 2011 report and Government response. 1.2.1 Developments since the Committee’s 2011 report The Committee acknowledged that, since their earlier report, patient safety and the treatment of complaints and concerns have become much higher profile issues and improvement has been made but there is “significant scope for further improvement” across the NHS, even in trusts regarded as high performers. They also recognised that, in the drive towards a more transparent NHS, the number of complaints about a provider, rather than being an indicator of failure, “may highlight a service which has developed a positive culture of complaints handling and it will be important for system and professional regulators alike to be able to identify the difference”. To enable monitoring in improvement of complaints handling by the successor Committee in the next Parliament, the Committee recommended that:  the Government should publish a detailed evaluation of the progress achieved, and work remaining to be undertaken, by the cross-service Complaints Programme;  the Department of Health should include an evaluation of the operation of the complaints system across the health sector in the light of the post- Francis changes. 1.2.2 Complaints handling by providers, commissioners and the professional regulators and Government reviews of progress In contrast to its 2011 recommendation that separate complaints systems and stratified standards may be best to meet patient and service user needs, in its 2015 report the Committee considers it would be desirable over time to bring health and social care complaints together. To achieve progress towards this, the Committee recommended that: 



The complaints system be simplified and streamlined by establishing a single complaints gateway across the NHS, for both providers and commissioners, including online availability, so that wherever a complaint is raised, it is the system, not the complainant, which is responsible for routing it to the appropriate agency to get it resolved. This streamlined process needs to be “adequately resourced”. Trusts must remain the leads in handling complaints made against their organisation. However, there is a greater role for commissioners to work constructively with providers on delivering improvements to services and to hold providers to account for delivering a well-functioning complaints system. CQC should remain responsible for examining the culture of complaints handling by providers. To meet the Francis recommendation that Trusts be assessed on how well they are handling complaints, Trusts should be required to publish at least quarterly, in anonymised summary form, details of complaints made against the Trust, how the complaints have been handled and what the Trust has learnt from them. The service-user led vision for complaints, ‘My expectations for raising concerns and complaints’, developed by the Parliamentary and Health Services Ombudsman in cooperation with system partners and stakeholders, was praised as best practice for first tier complaints handling.



  

 

There should be clear commissioning and consistent branding of PALS and NHS Advocacy services to make them as visible and effective as possible to any patient seeking assistance through the complaints process. Current complaints advocacy services were found to be hard to identify for members of the public and variable in their arrangements nationally. The Department of Health should also set out in its response to this report the progress has been made in reviewing the commissioning arrangements for advocacy services. The Government should complete a progress report on the functioning, funding and budgets of local Healthwatch organisations, due to concerns regarding the lack of ring-fencing of the funding provided for their use. Reform of the primary care complaints system, currently centralised by NHS England, to address current problems with fragmentation and loss of local knowledge, and to improve timely responses and local learning and improvement. The Committee agreed with the GMC that people wishing to give information about poor practice should be able to do so anonymously, but considered that medical professionals raising concerns about poor practice via a confidential helpline are under a professional duty to provide as much information as possible to enable the matter to be investigated and to put patients first. The GMC’s ‘Hooper Review’ will ensure that its practices and investigations adequately support registrants who genuinely raise patient safety concerns in the public interest, and protect them from retaliatory action. Essential” progress towards linking together professional regulation, system regulation and the complaints system should be monitored by the successor Committee in the next Parliament. Establishment of a single health and social care ombudsman, as a first step towards the integration of social care complaints into a single complaints system.

1.2.3 Second-stage complaints handling: the Parliamentary and Health Services Ombudsman The Committee recognised steps taken to improve complaints handling and investigations by the Parliamentary and Health Service Ombudsman in delivering on the Committee’s recommendations in 2011. However, serious criticisms of the Ombudsman’s handling of complaints prompted the Committee to recommend: 

an external audit mechanism be established to benchmark and assure the quality of Ombudsman investigations. The Ombudsman was asked to set out how her organisation is seeking to address problems with its processes, and a timetable for improvements.

1.2.4 Whistleblowers and staff who raise concerns: The Committee found that on-going poor treatment of whistleblowers has undermined trust in the system’s ability to treat staff who raise concerns fairly, with consequent implications for patient safety. To address this, there should be a programme to identify whistleblowers who have suffered serious harm and whose actions are proven to have been vindicated, and provide them with an apology and practical redress. The NHS must strive to emulate the complaints and concerns reporting culture that parallels other safety critical sectors such as aviation and nuclear energy. Locally we will consider the recommendations from this report. Our CQC report acknowledged that the Trust was seen as doing well with managing and responding to complaints and we have made further progress in the last 12 months. However we do acknowledge that there is always more to do. We will review our complaints and other processes in light of these recommendations and will report back to the Safety & Quality Committee.

The full Health Select Committee report is available at: http://www.parliament.uk/business/committees/committees-a-z/commons-select/healthcommittee/inquiries/parliament-2010/complaints-and-raising-concerns/

Local Issues

2.1

Opening of Earlswood Centre

Our diabetes and endocrine teams have now moved to the heart of our community with the opening of the new Earlswood Centre. This spacious new Centre means our team of consultants and four specialist nurses can provide separate clinics for people with Type 1 and Type 2 diabetes along with clinics for young adults and people using an insulin pump. This brings diabetes and endocrine care for local people into one place. On behalf of the Board I would like to thanks the whole team and also to the support teams who together have worked hard to make our plans a reality for patients. 2.2

Foundation Trust Membership

As we continue our journey to become a Foundation Trust that the numbers of patients and local people choosing to become an FT member continues to grow. We have now reached a membership total of 9,888 members (including staff). This is a great milestone for the Trust and our local community.

2.3

Launch of Macmillan Fundraising Appeal for East Surrey Hospital Cancer Information Centre

The launch of the appeal for the new Macmillan Cancer Support Centre which will be based at East Surrey Hospital took place on 27th January at Reigate Grammar School. It was good to see and meet so many people at the event which was hosted by newsreader Nicholas Owen, and their real enthusiasm to support us in building a specialist centre close to home that will provide specialist care and support. Gill Birch, from Redhill, spoke movingly about her experience of cancer treatment and her passion for making sure that that no-one faces cancer alone. 3.

Recommendation

The Board is asked to note the report and consider any impacts on the trusts strategic direction.

Michael Wilson Chief Executive February 2015

Date: 26th February 2015

TRUST BOARD IN PUBLIC

Agenda Item: 1.7 Board Assurance Framework & Significant Risk Register Gillian Francis-Musanu Director of Corporate Affairs Colin Pink Corporate Governance Manager

REPORT TITLE: EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Executive Team 18th February 2015

Action Required: Approval (√)

Discussion (√)

Assurance (√)

Purpose of Report: The BAF highlights potential risks to the Trust’s strategic objectives and mitigating actions, and the implementation of its programme of objectives for year one of the five year plan. The Significant Risk Register (SRR) details all risks on the Trust risk register system that are recorded as significant and the links to the Board Assurance Framework. Summary of key issues The BAF details 19 risks to the trusts strategic objectives, 5 of which are recorded as key strategic risks and red rated (Section 4). There are no new key issues to raise. There are 10 significant risks recorded on the Trust risk register, including one new risk relating to the continuing risk to the delivery of effective services and Trust strategic objectives caused by the resources required to actively manage the Trust’s rising sickness absence rate (1672). Recommendation: The Board is asked to discuss and approve the report and consider the following:  Review the BAF and its alignment to strategic objectives  Does the Board agree with the recorded controls and assurances  Approve the new risk added to the SRR Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact

The report is a requirement for all NHS organisations.

An Associated University Hospital of Brighton and Sussex Medical School

Financial impact Patient Experience/Engagement

As discussed in sections 5 (Income generation linked to activity referred to throughout the document) Patient experience and engagement is one of the Trusts strategic objectives. .

Risk & Performance Management

These are highlighted throughout the report.

NHS Constitution/Equality & Diversity/Communication

Discussed throughout the report but with the greatest detail in objective 3.

Attachment: February 2015 BAF and the current SRR

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 26th February 2015 BOARD ASSURANCE FRAMEWORK and SIGNIFICANT RISK REGISTER 1.

Board Assurance Framework

The Board Assurance Framework (BAF) describes the principal risks that relate to the organisation’s strategic objectives and priorities. It is intended to provide assurances to the Board in relation to the management of risks that threaten the ability of the organisation to achieve these objectives. The Trust has identified five main strategic objectives for 2014/15: 1) Safe: Deliver safe services and be in the top 20% against our peers 2) Effective: Deliver effective and sustainable clinical services within the local health economy 3) Caring: Ensure patients are cared for and feel cared about 4) Responsive to people’s needs: Become the secondary care provider and employer of choice for the catchment population 5) Well led: become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model These objectives are broken down into specific areas and the BAF details the key risks that the Trust faces to the delivery of these priorities. Each risk details the controls that are in place, the sources and effects of assurance and mitigating actions to reduce the likelihood of the impact of the risk materialising. (Some priorities have more than one associated risk) The Significant Risk Register (SRR) supports the BAF and details the highest rated operational risks that have been raised by the Executive Team and Divisional Management. The SRR is regularly reviewed and moderated by the Executive Team to ensure alignment with the BAF and other key risks to the Trust. 2.

Current status

The Executive team reviewed the existing BAF throughout February 2015 and have made minor updates accordingly. The changes made reflect conversations at the January public Board, updates on financial position and changes identified through reports reviews of assurances and actions considered by the Executive Team.

An Associated University Hospital of Brighton and Sussex Medical School

The 14/15 BAF (attached) details a total of 19 risks to the 5 Trust strategic objectives which are scored as follows: Objective 1.Deliver safe services and be in the top 20% against our peers 2.Deliver effective and sustainable clinical services within the local health economy 3.Ensure patients are cared for and feel cared about 4.Responsive - Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex 5. Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Total

Red (15-25)

Amber (8-12)

Green (1-6)

One of the purposes of the BAF is to ensure that all risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to green (low impact, low likelihood).The tables below highlight the predicted swing in risk rating. Table 1: Current BAF Risk Profile

An Associated University Hospital of Brighton and Sussex Medical School

Table 2: Target BAF Risk Profile

3.1 Headline information by objective (BAF) Objective 1 - Safe Deliver safe services and be in the top 20% against our peers

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

1.A.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties, supported by robust monitoring mechanisms (Page 2)

S4 x L3 = 12

S3 x L2 = 6

1.A.1 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care (Page 4)

S4 x L3 = 12

S5 x L2 = 10

Objective 2 - Effective â&#x20AC;&#x201C;Deliver effective and sustainable clinical services within the local health economy

Initial Risk Rating: Severity x Likelihood

2.A.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking outcomes are not utilised and implemented appropriately across divisions and specialties (Page 6) 2.B.1 There is a risk of a loss of elective business to outside provider if we do not align our activity to local commissioning priorities (Page 8)

Current Risk Rating: Severity x Likelihood

Target Risk Score

S3 x L3 = 9

S3 x L2 = 6

S2 x L2 = 4

S4 x L3 = 12

S4 x L1 = 4

An Associated University Hospital of Brighton and Sussex Medical School

Objective 3 - Caring – Ensure patients are Initial Risk cared for and feel cared about Rating: Severity x Likelihood 3.B.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and may impact negatively on Trust’s quality of care provided to patients (Page 9) 3.B.2 If the Trust does not put into place systems to assess, monitor and evaluate nursing staffing levels there may be negative impact on Trust’s quality of care provided to patients (Page 10) 3.D.1 There is a Risk that the Trust may not deliver continuous improvement to patient experience if the wider care and compassion strategy, vision and values are not embedded and sustained with all members of staff (Page 12)

Objective 4 – Responsiveness – Become the secondary care provider for the catchment population

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

S3 x L4 = 12

S3 x L2 = 6

S3 x L4 = 12

S3 x L3 = 9

S3 x L1 = 3

S2 x L4 = 8

S2 x L3 =6

S2 x L1 = 2

Current Risk Rating: Severity x Likelihood

Target Risk Score

S3 x L4 = 12

S4 x L4 = 16

S3 x L3 = 9

S3 x L2 = 6

S4 x L3 = 12

S4 x L2 = 8

S3 x L4 = 12

S3 x L2 = 6

Initial Risk Rating: Severity x Likelihood

5.A.1 Failure to deliver income plan (Page 17) 5.A.2 Failure to stop divisional overspending against budget (Page 18) 5.A.3 Unable to provide realistic medium term financial plan (Page 19) 5.A.4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position (Page 20) 5.B There is a risk that Clinical leadership efforts will not be embedded if staff do not feel empowered and supported in order to make positive changes regarding care pathways within specialties and directorates (Page 21)

Target Risk Score

S3 x L3 = 9

Initial Risk Rating: Severity x Likelihood

4.A Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care (Page 13) 4.A.2 As readmission rates are an indicator of high quality care, failure to improve the Trust’s rate poses a risk to this objective (Page 14) 4.D There is a risk that the Trust may not realise the benefits of service development opportunities which are fully appropriate for the local community unless partnership working and links between strategic partners are improved (Page 15) 4.E There is a risk that if That recruitment and retention strategies are not effective in attracting and retaining staff which will impact on our ability to develop and maintain services (Page 16)

Current Risk Rating: Severity x Likelihood

Target Risk Score

S5 x L3 = 15

S4 x L4 = 16

S4 x L2 = 8

S5 x L3 = 15

S4 x L4 = 16

S3 x L2 = 6

S5 x L3 = 15

S4 x L3 = 12

S4 x L2 = 8

S5 x L3 = 15

S4 x L3 = 12

S4 x L2 = 8

S4 x L1 = 4

An Associated University Hospital of Brighton and Sussex Medical School

Objective 5 â&#x20AC;&#x201C; Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

Initial Risk Rating: Severity x Likelihood

5.E.1 There is a risk that staff do not take up opportunities to participate in developmental programmes which could further impact upon staff development and missed opportunities to improve quality of care (Page 22) 5.G.2 If the Trust does not progress and deliver its Foundation Trust plans it is unlikely to be able to successfully authorised. This could leave the Trust without local autonomy and could lead to an alternative organisational form being imposed on the Trust. Which could reduce choice and focus on local health provision (Page 23) 5.F. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems (Page 24)

Current Risk Rating: Severity x Likelihood

Target Risk Score

S3 x L3 = 9

S3 x L2 = 6

S4 x L2 = 8

S4 x L1 = 4

S5 x L3 = 15

S5 x L2 = 10

Key risks Strategic risks Identified

The BAF highlights the following 5 key red risks (including proposed increase) to the Trust objectives that have been identified at time of updating the framework. These are: Risk description

Current rating

4.A Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care 5.A.1 Failure to deliver income plan 5.A.2 Failure to stop divisional overspending against budget 5.A.4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position 5.F. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems

S4 x L4 = 16

Target risk score

Page

S3 x L3 = 9

P13

S4 x L2 = 8

P17

S3 x L2 = 6

P17

S5 x L3 = 15

S4 x L3 = 12

P20

S5 x L3 = 15

S5 x L2 = 10

P24

S4 x L4 = 16 S4 x L4 = 16

5. Significant Risk Register On the 18th February the Executive Committee reviewed and agreed the content of the significant risk register. There are 10 risks on the Trust significant risk register. Each is in date and has mitigating actions to reduce the level of risk to an acceptable level. The Executive Committee reviewed and agreed the proposal to include one escalated risk to the significant risk register. Specifically the risk related to increasing sickness absence levels and the impact on day to day management and expenditure (1672). The committee agreed to de-escalate risk 1645, Loss of income and unnecessary expenditure as a result of the complexities associated with the maternity pathway, as sufficient action had been taken.

An Associated University Hospital of Brighton and Sussex Medical School

5.1 SRR Breakdown ID

Title

1401

Risk of outbreak of viral gastroenteritis

1491

Risk that non elective does not reduce and no payment in respect of marginal tariff Failure to maintain Emergency Department performance

1501

Patient admitted to the right bed first time

1480

1601 1602

1604

1605

1652

1672

Risk that demand growth activity does not deliver the plan Failure to stop divisional overspending against budget Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems The current local availability of qualified nurses and pressures on temporary staffing costs is effecting the Trust's ability to Increasing Sickness Absence Levels with impact on day to day management and expenditure

Initial Rating

Current Rating

Residual Rating

Next Review

31/03/2015

01/04/2015

6. Discussion/Action This report brings together the BAF for the Trusts strategic objectives and the Significant Risk Register into one report. The Board is asked to discuss and approve the report and consider the following:  Review the BAF and its alignment to strategic objectives  Does the Board agree with the recorded controls and assurances  Approve the new risk added to the Significant Risk Register. Colin Pink Corporate Governance Manager, February 2015 8

An Associated University Hospital of Brighton and Sussex Medical School

Appendix 1: Risk Appetite for 2014/15 The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives. The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. The key following principles further define this stance with an opinion from the Board: Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk only if, upon consideration, the benefits of the risk improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice. Target: Amber Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will endeavour to meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. Target: Green Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. There will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber Reputation: The board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. Target: Amber/Green

An Associated University Hospital of Brighton and Sussex Medical School

Page 1

Objective 1 - Safe â&#x20AC;&#x201C;Deliver safe services and be in the top 20% against our peers Priority ID and reference

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

1.A Consistently meet national patient safety standards in all specialties and across divisions 1.A.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties, supported by robust monitoring mechanisms. (Falls management is a specific focus and therefore highlighted)

Director responsible

Chief Nurse

Initial Risk Current rating

S4 x L3 = 12 S4 x L3 = 12

Target risk score

S3 x L2 = 6

Linked to Risk

1055 and 1545

Controls in place (to manage the risk)

Gaps in Control

1) Clinical teams to implement patient safety plans in the Trust (falls, pressure ulcers and infection control) 2) Regular review of patient safety data including the Safety Thermometer at divisional, executive and board level 3) Groups/Committee established including SQC, ECQR and its subcommittees, N & M and Divisional Governance. 4) Policies, procedures and guidelines provide the framework by which risks and incidents are managed. 5) Matron on site 7 days a week 6) Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) 7) Nursing and Maternity Strategy and Nursing staffing levels with daily real-time escalation 8) Incident reporting policy to be reviewed to include recent structural changes 9) Ward safety boards 10) Serious incident review group established to monitor and evaluate investigation progress and progress against actions

1) Lack of system to differentiate between Trust and community acquired cases of VTE

Specific Falls management controls 1) Falls management policy in place 2) Training undertaken for clinical staff in the assessment and management of patients at risk of falls 3) Falls pathway developed and operational for assessment of patient fall risk and those at risk of falling line in with NICE guidance June 2013 4) Patient falls strategic group meet monthly and report KPIs to the patient safety and clinical risk committee. 5) Falls Operational Board meet weekly to share investigation and learning from all complex, major and moderate falls. 6) Audit of falls policy and falls process undertaken and results and actions escalated to the appropriate operational and governance groups 7) Monthly reporting at Executive committee for Quality enabling improved understanding of falls and any gaps in falls management strategies 8) Divisional reporting, oversight and ownership of falls 9) Equipment audit and review undertaken 10) Falls and patient safety consultant nurse appointed, start date 1 December 11) Datix incident reporting in place and all serious falls investigated using SI methodology Page 2

Specific gaps in Falls management controls 1) ED Falls pathway â&#x20AC;&#x201C; under development 2) Consistency of joint working with community falls teams

12) Lead trust in south area falls network Potential Sources of Assurance (documented evidence of controls effectiveness)

Actual Assurances: Positive (+) or Negative (-)

1) Patient safety related KPI agreed and monitored at Board and Divisional Level 2)Meeting minutes and action plans, evidence of presentations and board discussion 3) External reports and visits both scheduled and unscheduled (including new CCG quality visits) 4) CQC intelligent monitoring rating 5) Patient tracking and analysis (Whiteboard project) 6) 15 Steps quality program

Positive (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) QGAF assessment and action plan (+) New EWS trialed and audited (+) Increase in reporting trends Negative (-) Never events incidence low (1 in last 12 Months, low harm) (-) NRLS reporting

Specific Falls management sources of assurance 1) 2) 3) 4) 5)

Datix incident reporting and analysis Monthly trust wide reporting using national benchmarking Training data Annual Falls Report 13/14 Clinical Nurse Consultant for Falls and Patient Safety commenced 4 December 2014

Specific assurances regarding Falls management Positive (+) Annual Falls report 2013/14 reduction in falls with harm in year (+) Resource focus on patient safety and falls (+) Evidence of improved SI investigation management and closures (+) Improved reporting of patient falls has enabled the Trust to understand fall profile and identify gaps in the falls management strategies available

Gaps in assurance

Assurance Level gained: RAG

Ability to benchmark in real time National Safety Dashboard to be implemented once produced

Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1) Establish links with falls team within community 2) Develop Emergency Department falls pathway

Update by

Page 3

FA 12/01/15

1) 2)

Date discussed at board

February 2015 Ongoing

To be discussed at February Board

Objective 1 - Safe â&#x20AC;&#x201C;Deliver safe services and be in the top 20% against our peers Priority ID and reference

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 1.A.1 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care

Controls in place (to manage the risk) 1)IPCAS Team and Group in place, Weekly taskforce in place 2)Infection control manual in place and information resources available 3)Antibiotic policy and guidelines in place 4)Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues. 5)MicroApp implemented for antimicrobial stewardship guidelines 6)Consultant led RCA and presentation of HCAI (MRSA, MSSA). This presentation is done in departmental meetings with IC doctor and Nurse attendance. This increases learning in the clinical team when compared to consultant attendance at IC meeting. 7) Prevalence studies and Enhanced surveillance of catheter-associated UTI part of annual programme. 8) 3 ICE-POD units in place â&#x20AC;&#x201C; ED, HDU and Hazelwood. 9) Developed a system where site team and matrons during the weekend are responsible in checking wards that have received positive results (See 4 above) 10)Focus on risk and mitigation of VHF involving ED/Micro/ITU/PHE 11)Antibiotic Stewardship group revitalized 12)Decontamination group informing development of strategy for IPCAS

Potential Sources of Assurance (documented evidence of controls effectiveness) 1)KPI indicators 2)Reducing numbers of cases of C. diff year on year 3)Divisional and departmental governance meeting minutes

Gaps in assurance Page 4

Director responsible

Medical Director

Initial Risk

S4 x L3 = 12

Current rating

S4 x L3 = 12

S5 x L2 = 10 Target risk score 1049 and 1050 Linked to Risk Gaps in Control 1)Risk assessment of patients with diarrhoea is not consistent, in particular on admission and at first onset 2)Variation in line care demonstrated by audit 3)High bed occupancy can cause infection control risk to increase (e.g. side room availability)

Actual Assurances: Positive (+) or Negative (-) Positive (+)No C. diff outbreaks declared in year 2013/14 (+)CQC visit Feb 2013 found no immediate concerns (+)Antimicrobial prescribing audit compliance (+)Actions taken as part of annual program (+) Recent CQC inspection highlighted improvements in MRSA screening (+)TDA visit inspecting controls and procedures (+)PHE and NHSE walkthrough ED for VHF risk provides good assurance (+)Data quality indicated in Internal Audit of Quality Account (2013/14) (+)First seasonal outbreak of Norovirus 2014/15 was contained to one area (+)Incidence of CDI 2014/15 Negative (-)3xMRSA BSI case during 2013/14, 0 to date 2014/15 (-)Period of increased incidence of CDI Godstone ward, typing suggests cross infection

Assurance Level gained: RAG

Extensive auditing and monitoring in place. Trust position known Mitigating actions underway 1) Roll out of Urinary catheter Passport 2) Full list of actions in IPCAS Annual Programme of work 3) Ongoing discussion with commissioners about penalties applying only to cases with poor/inadequate care. This conversation is nationally mandated DH 22/01/15 Update by Date discussed at Board

Page 5

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Embedding 2) 2014/15 3) Ongoing To be discussed at February Board

Objective 2 - Effective â&#x20AC;&#x201C;Deliver effective and sustainable clinical services within the local health economy Priority ID and reference

2.A Achieve the best possible clinical outcomes for our patients

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

2.A.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking outcomes are not utilised and implemented appropriately across divisions and specialties

Director responsible

Chief Nurse / Clinical Leads

Initial Risk Current rating

S3 x L3 = 9 S3 x L2 = 6

Target risk score

S2 x L2 = 4

Linked to Risk

844

Controls in place (to manage the risk) 1) Safety thermometer data is reviewed by wards and specialties at regular meetings 2) HSMR/SHMI/Datix incidents are reviewed at divisional and trust level 3) Groups/committees established including SQC, ECQR and its subcommittees 4) Specialty deep dive process identified areas of best practice and also areas for improvement, which have been actioned and monitored by relevant clinical leads

Gaps in Control 1) Evidence of learning from incidents/outcomes

Potential Sources of Assurance (documented evidence of controls effectiveness) 1. Regular data collection 2. PROMS 3. Minutes of divisional meetings including M & M 4. Minutes of Clinical Effectiveness and Patient Safety and Risk subcommittees 5. Patient tracking and analysis (whiteboard project) 6. Datix reporting and analysis 7. Clinical Nurse Consultant for Patient Safety and Falls commenced 02/12/14

Actual Assurances: Positive (+) or Negative (-)

Gaps in assurance Ability to benchmark in real time National Safety Dashboard to be implemented when available Mitigating actions underway

Positive (+) CQC Chief Inspector of Hospitals Report

(+) CQC risk rating, lowest possible (+)The latest HSMR data shows overall Trust mortality is lower than expected for our patient group (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) New EWS implemented (+) Increase in reporting trends (+) National falls data benchmarks favorably (Trust desire to improve position) Negative (-) Never events incidence low (1 in last 12 Months, low harm) (-) NRLS reporting Assurance Level gained: RAG

1) Development of ward based performance dashboards Update by Page 6

FA 12/01/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Start date 12/01/2015 To be discussed at February Board

Objective 2 - Effective â&#x20AC;&#x201C;Deliver effective and sustainable clinical services within the local health economy Priority ID and reference

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

2.B Deliver services differently to meet need of patients, the local health economy and the Trust 2.B.1 There is a risk of a loss of elective business to outside provider if we do not align our activity to local commissioning priorities

Director responsible

Chief Operating Officer

Initial Risk Current rating

S4 x L3 = 12 S4 x L3 = 12

Target risk score

S4 x L1 = 4

Linked to Risk

No specific risk recorded on the operational risk register

Controls in place (to manage the risk) 1) Local Transformation Board 2) 3x3 meetings 3) CEO strategic meetings 4) Partnership boards

Gaps in Control 1) Pathway redesign needs to ensure its appropriate and fit for purpose 2) Still to agree 15/16 contract with BICS

Potential Sources of Assurance (documented evidence of controls effectiveness) 1)Letters of intent 2)Contracts 3)Meeting minutes

Actual Assurances: Positive (+) or Negative (-) Positive (+) Commitment from all parties, initial plans and agreements good (+) Consultant engagement in pathway redesign (+) Recent experiences and management of Dermatology services (+) Current referral flows likely to remain until Q1 2015/16 (+) Contract 14/15 signed with BICS Negative (-) Other services provided could be effected by the outcome of this model

Gaps in assurance Contract to be agreed with BICS, undefined staff model (TUPE) and activity undefined

Assurance Level gained: RAG

Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1)Appropriate pathways to be determined and developed 2)Currently Negotiating 15/16 contract with BICS

1)Q4 2014/15 2)Q4 2014/15

Update by

Page 7

PB 09/02/15

Date discussed at Board

To be discussed at February Board

Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference

3.B Deliver high quality care around the individual needs of each patient

Key Action for 2013/14 objectives and description of any potential significant risk to this priority

3.B.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and may impact negatively on Trust’s quality of care provided to patients.

Director responsible

Chief Nurse and Medical Director

Initial Risk Current rating

S3 x L3 = 9 S3 x L4 = 12

Target risk score Linked to Risk

S3 x L2 = 6 1416

Controls in place (to manage the risk) 1. Workforce KPIs including vacancy rates, turnover and temporary staffing monitored by Workforce subcommittee, Exec Committee and the Board 2. Nursing Recruitment plans developed by DCN and DCM in response to Right Staffing review and monitored through Agency PMO, Workforce subcommittee and divisional team meetings 3. Recruitment process reviewed, KPIs under development to provide assurance 4. Bank workstream developed and bank recruitment in progress to reduce use of agency nursing staff 5. Review of MAST and induction processes to be undertaken to ensure they meet operational requirements 6. Marketing plan in development 7. Weekly PMO focusing on agency usage 8. SASH funded by HEKSS to develop and lead on physician associate training and recruitment for SEC 9. SNCT data presented and approved at November Board 10. Foundation doctors workloads re-modelled such that 95% of time is spent with no more than 14 patients.

Gaps in Control 1) E-Roster system is not updated out of hours 2) Unfilled agency shifts 3) Staffing Ratios in some areas of the Trust at night are under review 4) The Trust still carries a volume of vacancies specifically within ITU and theatres 5) Imperfect induction for short notice, short term medical locums 6) Aiming for full recruitment (influenced by HEKSS)

Potential Sources of Assurance (documented evidence of controls effectiveness) 1. Ward staffing templates monitored daily by Matrons and escalated to the Divisional Chief Nurses to ensure safe levels to meet patient needs. 2. Incident reporting via Datix demonstrating patient or staff harm 3. Staff absence reports 4. % of vacant shifts filled by Trust and agency staff 5. Number /severity of issues escalated to relevant agency 6. Daily Nursing review “planned vs actual” 7. References from other local employers 8. Revalidation (GMC) for locums 9. SOP developed for the management of nursing staffing Gaps in assurance Trust position known - no identified gaps in assurance

Actual Assurances: Positive (+) or Negative (-)

Mitigating actions underway Page 8

Positive (+)SNCT data (+)Further recruitment planned has been undertaken Negative (-)Benchmarked high proportion of agency staff usage against other Trust’s (-)Vacancy rates and turnover rates

Assurance Level gained: RAG

Progress against mitigation (including dates, notes

1)Continue to monitor recruitment drives 2)Implement latest version of E-Roster (better utilisation of bank staff) 3)7 day working plans for medical staff under development across the Trust FA 12/01/15 and Update by Date discussed at Board DH 22/01/15

Page 9

on slippage or controls/ assurance failing. 1) Underway and ongoing 2) Being implemented 3) Embedding and under review To be discussed at February Board

Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference Key Action for 2013/14 objectives and description of any potential significant risk to this priority

3.B Deliver high quality care around the individual needs of each patient

3.B.2 If the Trust does not put into place systems to assess, monitor and evaluate nursing staffing levels there may be negative impact on Trust’s quality of care provided to patients. Controls in place (to manage the risk) 1. Ward staffing templates monitored daily by Matrons and escalated to the Divisional Chief Nurses to ensure safe levels to meet patient needs. 2. Planned versus actual staffing levels on a shift by shift basis and evidence actions taken 3. Procurement of updated e roster system. 4. SNCT tool 5. Agency staff sourced from agencies known to and contracted by Trust. Issues regarding agency staff practice are subject to formal arrangements between the agency and the Trust any unresolved concerns are escalated and managed by Deputy Chief Nurse. 6. Robust recruitment process to both substantive and bank staff posts including overseas recruitment 7. Monitoring of Safety Thermometer, patient experience and staff turnover, sickness at ward level 8. Matron for workforce recruited Potential Sources of Assurance (documented evidence of controls effectiveness) 1. Daily ward staffing review and reporting 2. Incident reporting via Datix demonstrating patient or staff harm 3. Staff absence reports 4. % of vacant shifts filled by Trust and agency staff 5. Number /severity of issues escalated to relevant agency 6. SNCT data presented at November Board 7. Increased reporting of positive patient experience in relation to staffing/high quality care and compassion reported 8. Gap analysis against ‘Right Staffing’ report and current ward staffing levels undertaken 9. Gaps filled by using staff flexibly across the Divisions with bank staff used in priority to agency. 10. Review of maternity staff ratio undertaken 11. Monthly reporting of nursing staffing levels with actions taken to mitigate to Trust Board Gaps in assurance Trust position known no identified gaps in assurance

Page 10

Director responsible

Chief Nurse

Initial Risk Current rating

S3 x L4 = 12 S3 x L3 = 9

Target risk score Linked to Risk

S3 x L1 = 3 1447

Gaps in Control 1. E-Roster system is not updated out of hours 2. Trust does not currently have the latest version of E-Roster that is more effective at accessing and utilizing Bank Staff 3. Unfilled agency shifts 4. Staffing Ratios in some areas of the Trust at night are under review 5. The Trust still carries a volume of vacancies specifically within ITU and theatres

Actual Assurances: Positive (+) or Negative (-) Positive (+) CQC Chief Inspector of Hospitals Report (+) Daily ward staffing review (+) Reports regarding reducing vacancy rates, sickness, absence (+) Incident reporting via Datix (+) Patient experience data by ward or unit Negative (-)Benchmarked high proportion of agency staff usage against other Trust’s (-)Vacancy rates and turnover rates

Assurance Level gained: RAG

Mitigating actions underway 1. 2.

Implement e-roster upgrade and utilize core functionality (bank and messaging) Implement plans to manage staffing issues in ITU and Theatres

Update by

Page 11

FA 12/01/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) March 2015 2) TBA To be discussed at February Board

Objective 3 - Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about Priority ID and reference

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

3.D Treat patients and their families with dignity, respect and compassion

Director responsible

Chief Nurse / Director of HR

Initial Risk

S2 x L4 = 8

3.D.1 There is a risk that the Trust may not deliver continuous improvement to patient experience if the wider care and compassion strategy, vision and values are not embedded and sustained with all members of staff.

Current rating

S2 x L3 = 6

Target risk score

S2 x L1 = 2

Linked to Risk

No specific risk recorded on the operational risk register, 20 risk monitored by the Executive patient experience committee

Controls in place (to manage the risk)

Gaps in Control

1) Trust values embedded and disseminated across organization 2) Nursing and Midwifery Strategy implemented including 6 Câ&#x20AC;&#x2122;s 3) Values based recruitment integral to nursing and midwifery recruitment and performance management/appraisal 4) Customer care training undertaken with OPD and ED front line staff 5) YCM and F&FT feedback shared with clinical and non-clinical staff. Actions plans developed in response 6) Work underway to ensure staff are treated with respect by patients & other staff

1) Evidence of shared learning across divisions and clinical units 2) Standarised appraisal and performance management process 3) Ability to roll out customer care training across organisation

Potential Sources of Assurance (documented evidence of controls effectiveness)

Actual Assurances: Positive (+) or Negative (-)

1) Work in progress to develop and roll out GE leadership development including values and organisational development (SASH Plus) 2) YCM and FFT 3) Datix and patient compliments and complaints

Positive (+) CQC Chief Inspector of Hospitals Report (+) Staff survey (+) YCM and FFT score (above average for inpatients) (+)The August FFT score for ED was +81, the highest score to date. Since December 2013, the (+)ED FFT score has been between +75 and +81, well above the National average. (+) The Inpatient score has risen by 2 points this month to +84, the inpatient FFT scores have been between +80 and +84 since March2014. (+) Incident reporting (+) pilot of 8a and above appraisal process incorporating assessment against behaviours Negative (-) Complaints received relating to patient experience (-) FFT response rates variable (-) Appraisal rates recorded

Gaps in assurance Trust position known no identified gaps in assurance

Assurance Level gained: RAG

Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1)Customer care training pilot 2)Evaluate effect of pilot and consider wider role out 3)Role out Behavioural Anchors developed through SASH Plus and embed values in staff appraisal 4)Output of pilot of new Achievement Review process (which includes appraisal of behaviours) being worked through

1)Complete 2)Underway 3)Apr 2015

Update by Page 12

FA 12/01/15 and JM 19/01/15

Date discussed at Board

To be discussed at February Board

4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference

4.A.1 Deliver access standards

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

Controls in place (to manage the risk) 1) EDD Patient Pathway 2) Site management team and Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches on weekly to implement lessons learnt 5) Site Management Team and Discharge Team 6) Circa 50 additional community beds made available 7) 7 day medical consultant ward rounds established 8) Additional community beds 9) Extra 10 surgical beds for 3 months (Dec –Feb) to support elective flow and reduced cancellations 10) Capel Annex opened 1/12 (20 beds) 11) AMU Annex opened 29/12 (12 beds until 28/2) Potential Sources of Assurance (documented evidence of controls effectiveness) 1) NHS England aware 2) Combined weekly Quality and Performance Dashboard for ED reporting on a combination of quality and safety standards and the ED national indicators reported to exec meeting weekly 3) Performance Management Framework and reporting to Trust Board 4) External stakeholder inspections 5) Daily sit rep reporting to the TDA 6) Daily winter Sit Reps (Commenced November) Urgent Careboard Area Team. 7) Whole system operational resilience plans signed off for 14/15 8) 2020 whole system review of discharge process, reviewing recommendations

Gaps in assurance Winter plans and local health economy position going into winter months Mitigating actions underway

Director responsible

Chief Operating Officer

Initial Risk Current rating

S3 x L4 = 12 S4 x L4 = 16

Target risk score

S3 x L3 = 9

Linked to Risk

1220 and 1491

Gaps in Control 1)Identified on a rolling basis as part of weekly review 2)It is difficult for the Trust to influence the output of decision making across the local health economy 3)Ambulatory pathways yet to imbed

Actual Assurances: Positive (+) or Negative (-) Positive (+) ED Standard delivered Q1 and Q2 narrowly missed Q3 (+) Maintaining top 20% performance (+) Process improvement (+) Working with partners commissioners / partners to expedite flow through hospital (Medihome and community beds) (+) Top 20 patient delay weekly meetings Negative (-) Quality indicators for time to assessment / treatment. Surrey and Sussex local lead. (-) EDD Section 2 and section Patient tracking system (-) Number of patients safe to discharge at any one time (-) Adult Bed occupancy remains higher than plan due to increased activity (-) Increase in no of medically fit for discharge patients Christmas New Year period Assurance Level gained: RAG

1) Rolling bed capacity plans being reviewed Update by Page 13

PB 09/02/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1)Ongoing To be discussed at February Board

Objective 4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference

4.A.2 Deliver access standards

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

4.A.2 As readmission rates are an indicator of high quality care, failure to improve the Trust’s rate poses a risk to this objective

Controls in place (to manage the risk) 1) Discharge processes in place, Medical and MDT fit 2) Dr Foster report re-admission monthly (monitored by clinical effectiveness and ECQR) 3) Data review for pathway specific re-admissions 4) Change of some patient episodes to reflect out-patient contact rather than readmission 5) Establish Frailty Service in community staffed with HCE Consultants to reduce need for readmission 6) White board project facilitates agreement and work towards agreed date of discharge. Potential Sources of Assurance (documented evidence of controls effectiveness) 1) KPIs 2) Dr Foster alerts 3) Regular audit review of readmissions at service level 4) Joint Audit with Clinical Commissioning Groups 5) Triangulation with other data sets (e.g. VTE)

Director responsible

Medical Director

Initial Risk Current rating

S3 x L3 = 9 S3 x L3 = 9

Target risk score

S3 x L2 = 6

Linked to Risk

No specific risk recorded on the operational risk register, 20 risk monitored by the Executive patient experience committee

Gaps in Control 1) Temporary notes makes clinical coding more difficult , but are reducing in numbers 2) Not all elements of pathway under central oversight

Actual Assurances: Positive (+) or Negative (-) Positive (+) Re-admission data no longer flags on “Dr Foster” reports (+) Re-admission data work by local physicians (+) Internal audit of readmission figures provides positive assurance (+) Feedback following initial work on discharge process 2013/14 (+) RCA on areas highlighted by Dr Foster

Negative (-) Readmission data quality Gaps in assurance 1)Exact definition of re-admission required Mitigating actions underway

Assurance Level gained: RAG

1) Safer discharge practices agreed by local healthcare providers, discharge to access pilot 2) Data quality coding 3) OPAL Service linked to GP 4) Review storage of medical records to reduce need for temporary notes 5) Work to improve coding at ward level on clear signaling of planned readmission (TWOC) Update by Page 14

DH 22/01/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Under review 2) Underway 3) Underway 4) Tendering at present 5) Underway To be discussed at February Board

Objective 4 - Responsive to peopleâ&#x20AC;&#x2122;s needs â&#x20AC;&#x201C; Become the secondary care provider of choice for the catchment population 4.D Develop local services as appropriate at East Surrey Hospital, other Trust sites and in the community Key Action for 2014/15 objectives 4.D There is a risk that the Trust may not realise the benefits of and description of any potential service development opportunities significant risk to this priority which are fully appropriate for the local community unless partnership working and links between strategic partners are improved Controls in place (to manage the risk) 1) Local Transformation Board 2) 3x3 meetings 3) CEO strategic meetings 4) Partnership boards

Director responsible

Chief Operating Officer

Initial Risk

S4 x L3 = 12

Current rating

S4 x L3 = 12

Target risk score

S4 x L2 = 8

Linked to Risk

1501, 1270, 1491, 1164, 1332

Potential Sources of Assurance (documented evidence of controls effectiveness) 1)Letters of intent 2)Contracts 3)Meeting minutes

Actual Assurances: Positive (+) or Negative (-)

Priority ID and reference

Gaps in Control 1)Length of stay needs to reduce 2)Repatriation of tertiary services effected and influenced by external factors

Positive (+) Joint working with Royal Surrey County ( Chemeo and Radiotherapy) (+) Pathology joint venture BSUH (+) Bowel screening (+) BOC respiratory unit (+) Initial work on repatriating Cardiology Lab (8 wk pause to support winter pressures) (+) Winter beds initiative 2013/14 (+) Business case new surgical ward and additional theatre

Gaps in assurance Trust position known no identified gaps in assurance

Assurance Level gained: RAG

Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1)Q4 2014/15

1)Decant ward established and operational

Update by

Date discussed at Board PB 09/02/15

Page 15

To be discussed at February Board

Objective 4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

4.E Develop local services as appropriate at East Surrey Hospital, other Trust sites and in the community 4.E There is a risk that recruitment and retention strategies are not effective in attracting and retaining staff which will impact on our ability to develop and maintain services.

Director responsible

Director of Human Resources

Initial Risk

S3 x L4 = 12

Current rating

S3 x L4 = 12

Target risk score

S3 x L2 = 6

Linked to Risk

1580

Controls in place (to manage the risk)

Gaps in Control

1) Workforce & OD Strategy with vision to be “Employer of Choice” 2) Key Theme of W&OD Strategy is Recruitment and Retention with key objectives for short, medium and long term 3) Finance and Workforce Committee receives monthly updates on key themes 4)Executive Committee for Quality & Risk through Workforce Sub-group considers workforce metrics and risks. 5)Workforce metrics – turnover and vacancy rate reported at Divisional and Trust level. 6)Specific Nursing Recruitment & Retention workstream Chaired by Chief Nurse reports into Workforce Committee via Deputy Chief Nurse

1) Nature of workforce skills means that “Employer of Choice” must not be restricted to catchment populations of Surrey & Sussex. The Trust must be free to recruit for the skills required as these may not be present in the locality. The benefits of employment on population health and life expectancy mean that the Trust should where appropriate recruit from the locality.

Potential Sources of Assurance (documented evidence of controls effectiveness)

Actual Assurances: Positive (+) or Negative (-)

1) Performance reports and minutes of committee meetings 2) Progress on Workforce Strategy

Positive (+) Trust vacancy rate (+) Hospital Intelligent Monitoring report for July 2014 – no elevated risks flagged for workforce Negative (-) Trust Turnover rate (-)Draft Hospital Intelligent Monitoring report for Oct 2014 – indicates low risk relating to nursing turnover benchmark

Gaps in assurance Assurance Level gained: RAG 1) Subjective factors in employee motivation and long lead in time mean it is difficult to monitor ‘cause and effect” for R&R initiatives 2) Performance reporting is not currently configured to report at Service Line level Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Monthly reporting of metrics 2) Task & finish group with key deliverables

Update by

Date discussed at Board JM 19/01/15

Page 16

1) Ongoing

To be discussed at February Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5.A.1 Failure to deliver income plan

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S4 x L4 = 16

Target risk score Linked to Risk

S4 x L2 = 8 1479,1480,1601,1648,1649

Controls in place (to manage the risk) 1) Business Plans and budgets (activity and financial) savings / transformation plans. 2) Signed contracts with both main sets of commissioners (NHSE and CCGs). 3) Contract management process in place - clearer and better structure than last year. 4) Financial reporting, including forecast scenarios presented to Board Please note that the linked SRR risks refer to shortfall in elective income (1601), maternity pathway risk (1645) and (a non –finance risk) the level of emergency demand (1491) Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Management Board and Trust Board (including CQUIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output and reporting from health system management (e.g.: System Resilience group) 5) Output of Contract Management Process - including the output from Activity Query Notice process.

Gaps in Control 1) A Chief Officer meeting has replaced the LTB but it is still establishing its structures – these are anticipated to be in place soon, but there is a question over the effectiveness of health system forums to manage emergency activity actions (this was subject to discussion on 26 Jan at Chief Officer Mtg) 2) No agreement over repayment of withheld marginal rate emergency tariff or completion of activity query process (action in train) 3) CCG plans make significant assumptions on activity reductions that are not being adjusted by them in response to actual outturn and there is a widening gap between their plan and actuals – this is impacting elective activity as well as driving cost and providing the “wrong” income. (Activity Query Notice in train).

Actual Assurances: Positive (+) or Negative (-)

Positive (+) 2013/14 activity and income met the Plan (+) Reconciliation process working with CCGs at the moment (avoiding delay to disputes) - that continues to be the case at M07 (+) settlement of 13/14 Surrey income dispute, also settlement of first 2014/15 dispute with NHS England. Negative (-) At M10 there continues to be adverse variance against plan in several areas – this includes the maternity pathway, radiology (both areas now improving) and elective activity – however, income is better than expected at M10 (-) From July to date emergency activity is higher than it has ever been, putting pressure on elective income, costs and providing the “wrong” income. (-) Too much non elective activity, not enough elective. Gaps in assurance Assurance Level gained: Amber None as yet, but adverse variances within the actual value of income collected leaves this as amber. Mitigating actions underway 1) Regular Contract monitoring meetings in place and working – payments are now having to be chased with CCGs; 2) Ongoing internal review actions operating – income variances being tracked and fed into PMO discussions – specific detail being followed up in adverse areas (e.g.: radiology, maternity) 3) Trust is bringing action to a conclusion in respect of the 30% marginal rate tariff payment. PS 16/02/2015 Update by Date discussed at Board

Page 17

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Actions proceeding to timetable – M10 shows additional income but also additional over spending.

To be discussed at February Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5.A.2 Failure to stop divisional overspending against budget

Controls in place (to manage the risk) 1) Business Plans and budgets (activity and financial) savings / transformation plans 2) Divisional activity plans agreed & signed off 3) Internal Performance Review (PMO) process and CEO review 4) Forecast scenarios presented to Board 5) M06 forecast process sees all Divisions working to clear targets Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Management Board and Trust Board (including CQUIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output in financial reporting describes improvement and risk mitigation. 5) Agency PMO.

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S4 x L4 = 16

S3 x L2 = 6 Target risk score 1602, 1663 Linked to Risk Gaps in Control 1) There are some areas in the Trust where variance from budget is significant and reduction of spend is not appropriate – these budgets need to be reviewed (and that will form part of 2015/16 budget setting)

Actual Assurances: Positive (+) or Negative (-) Positive (+) Corporate budgets within tolerance. (+) budgets corrected for undeliverable savings and contingency found. (+) forecasts have been reviewed and nominal permission to overspend given where appropriate, with action in other areas. Negative (-) Emergency activity pressures are greater than expected (-) YTD all Divisions are overspent (please note comments on control through forecast process). (-) Overall agency cost remains high. (-) M10 variance from forecast is adverse although income is favourable. Overall risk for BAF “red” – assurance rating also “red” noting position on overspend action planning.

Gaps in assurance

Assurance Level gained: Red

Please note comments above – budgets are overspent, but overspending levels have been agreed (nb: not as final control totals yet) and action is being linked to that work. The assurance level remains red, as some of the stretch actions present risk. Mitigating actions underway 1) PMO/Performance structure continues - M10 PMOs now complete 2) Controls are being exercised in divisions and centrally (vacancies are passed through Execs, procurement management etc.) 3) Contingency action around emergency and elective activity is now being implemented with the opening of additional capacity. PS 16/02/2015 Update by Date discussed at Board

Page 18

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Actions proceeding to timetable

To be discussed at February Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5.A.3 Unable to provide realistic medium term financial plan

Controls in place (to manage the risk) 1) Items referred to in 5.A.1 and 5.A.2 above 2) V5.0 long term financial model and integrated business plan completed (submitted to TDA in September 2014) 3) TDA Plan submitted in January 2015 4) Board to Board held with the TDA in November 2014.

Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Delivery of current year financial plans 2) Delivery of long term financial model and integrated business plan documentation, and delivery against them

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S4 x L3 = 12

S4 x L2 = 8 Target risk score 1603 Linked to Risk Gaps in Control 1) Items listed above (5.A.1, and 5.A.2) are applicable here 2) Elements of 2014/15 planning cannot yet be incorporated in Trust financial planning (e.g.: Better Care Fund implications) because of lack of detail. 3) Lack of alignment between CCG activity plans and actual performance. 4) Reliance on centrally determined rules for PbR, Better Care Fund and the wider NHS finance regime.

Actual Assurances: Positive (+) or Negative (-) Positive (+) Delivery of performance in 2013/14 (+) 5 versions of LTFM submitted – each has passed muster with TDA high level review although it has not been subject to full challenge and scrutiny. (+) LTFM submitted describes viable position (+) TDA have provided positive feedback following Board to Board. Likely next stage is a Monitor “preassessment” review Negative (-) Performance in 2014/15 provides risk (-) alignment with CCG plans is not clear. There are significant differences between actual performance on activity and CCG plans. (-) Lack of clarity on significant changes from Better Care Fund.

Overall, on basis of current assumptions and delivery of LTFM, RAG reduced to amber. Assurance RAG amber. Gaps in assurance Assurance Level gained: Amber Revised LTFM (long term financial model) and IBP (Integrated Business Plan) currently being prepared but not yet complete Mitigating actions underway

1) Monitor “pre-assessment” review has been undertaken, and, once the outcome is known, a revised LTFM will be prepared. Update by

Page 19

PS 16/02/2015

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Progress is on timetable To be discussed at February Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5.A.4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score

S4 x L3 = 12

Linked to Risk

1604

Controls in place (to manage the risk) 1) Bi weekly review of forward cash flow by finance team and CFO 2) Cash and working capital policy and strategy 3) Annual cash plan linked to business plan and capital plan ( see link with Risk 1134)

Gaps in Control 1) Problems with Commissioners delivering to agreed cash flow dates.

Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Twice monthly reporting to CFO by finance team, SBS reporting on bank balance 2) Monthly finance reporting to Executive Committee and Trust Board

Actual Assurances: Positive (+) or Negative (-) Positive (+) Positive cash flow reported for 2013/14 - temporary borrowing needed in 2013/14, but reasons for that were delays in agreements (CCG and TDA) – temporary borrowing repaid in full by 31 March 2013 (+) Liquid ratio has followed expectations (+) Cash remains on plan in M09 2014/15 Negative (-) no confirmed additional cash to resolve underlying liquidity problem – likely to be resolved in FT application process – potentially through a working capital loan (-) cash flow dependent on financial outturn described in 5.A.1 and 5.A.2 above. (-) remedial action has had to be taken at M09 to secure cash from Commissioners. Overall rating “red” noting risk to forecast I&E. Assurance RAG "amber" - no current cash problem but underlying problem unresolved.

Gaps in assurance Assurance Level gained: Amber In terms of cash flow management to end year, no material gaps in assurance. In terms of resolving the actual risk (liquidity), there is no confirmation of additional cash to resolve SoFP weakness. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Day to day cash control is main action currently, coupled with actions to maintain service income and Actions proceeding to timetable manage spend 2) Long term financial model, and TDA plan now provides additional validation of the level of cash injection required and the interaction from an improving financial position within the model 3) Discussion will continue with the TDA as the FT timeline progresses. PS 16/02/2015 To be discussed at February Board Update by Date discussed at Board

Page 20

Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5.B We are an organisation that is clinically led and managerially enabled 5.B There is a risk that Clinical leadership efforts will not embed if staff do not feel empowered and supported in order to make positive changes regarding care pathways within specialties and directorates

Director responsible

Medical Director

Initial Risk Current rating

S4 x L2 = 8 S4 x L1 = 4

Target risk score

S4 x L1 = 4

Linked to Risk

No specific risk recorded on the operational risk register, 14 risk monitored by the Executive patient experience committee

Controls in place (to manage the risk) 1)JD and appointments to reflect importance of Chiefs and clinical leads 2)Joint work with Clinical leads and Exec Team undertaking the opportunity to work with GE 3)Work of Clinical leaders in many significant projects draws on and underlines the value of clinicians as leaders 4)Implementation of Trial appraisal using â&#x20AC;&#x153;talent mappingâ&#x20AC;? methodology to promote succession planning 5)Clinical Leads meeting frequency increased to twice monthly

Gaps in Control 1)Variation in priorities of clinical leads 2) Some departments are small with no appropriate interest in clinical management.

Potential Sources of Assurance (documented evidence of controls effectiveness) 1) 1:1 training 2) Board presentations SQC, Prescribing committee 3) HEKSS established dentistry school

Actual Assurances: Positive (+) or Negative (-)

4) GMC survey highlights no safety concerns (for the first time) 5) Talent review and achievement review at appraisal 6) Increased interest in clinicians wanting to lead and manage

Gaps in assurance Trust position known no identified gaps in assurance

Positive (+) CQC report and feedback (+) GE updates (+) Increasing buy in from clinical leads to leadership agenda (+) Overall staff survey (+) Deanery reports Negative (-) GMC survey training results , some areas report undermining Assurance Level gained: RAG

Mitigating actions underway 1)Ongoing work to embed Clinical Leads in activities to support strategic objectives 2)Delivery of outputs of SASH Plus (Appraisals)

Update by

Date discussed at Board DH 22/01/15

Page 21

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1)Next phase commenced August 2014 2)April 2015

To be discussed at February Board

Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5.E Have appropriately qualified and competent staff always working to the highest standards of professionalism and ethics 5.E.1 There is a risk that staff do not take up opportunities to participate in developmental programmes which could further impact upon staff development and missed opportunities to improve quality of care

Director responsible

Director of Human Resources

Initial Risk

S3 x L3 = 9

Current rating

S3 x L3 = 9

Target risk score

S3 x L2 = 6

Linked to Risk

1170

Controls in place (to manage the risk)

Gaps in Control

1) Personal Development Plans as part of Appraisal identify development needs 2) Training Need’s Analysis at Divisional level extrapolated to Trust level inform strategic planning of development priorities. 3) Analysis of education and training activity 4) Make available e learning packages as an alternate to face to face training implement new delivery model on yearly cycle (elearning one year face to face the next) 5) Pilot elearning and roll out across Trust 6) OLM configured to capture locally delivered MAST programmes

1) Reporting of development that is undertaken within Divisions

Potential Sources of Assurance (documented evidence of controls effectiveness)

Actual Assurances: Positive (+) or Negative (-)

1) PDP’s 2) Training needs analysis update to August 2014 Finance Investment and Workforce Committee 3) Monthly reporting against 10 Core Mandatory Training subjects at Divisional and Trust level at Finance Investment and Workforce Committee through ECQR&CC – Workforce Committee.

Positive (+)Trust utilises HEKSS central funding (+)TNA update to August 2014 Finance Investment and Workforce Committee

Negative (-) Bursary funding being restructured under national ‘costings’ exercise (-) Compliance rates for MAST programme

Gaps in assurance

Assurance Level gained: RAG

Reporting of development that is undertaken within Divisions

Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1) Reporting structure in ESR being reconfigured

1) Ongoing

Update by

Page 22

JM 19/01/15

Date discussed at Board

To be discussed at February Board

Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference

5.G.2 We are a well governed organisation

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5.G.2 If the Trust does not progress and deliver its Foundation Trust plans it is unlikely to be able to successfully authorised. This could leave the Trust without local autonomy and could lead to an alternative organisational form being imposed on the Trust. Which could reduce choice and focus on local health provision

Controls in place (to manage the risk) 1)BGAF assessment carried out and action plan in place 2)Corporate governance framework in place 3)Foundation Trust project board meeting 6 weekly 4) FT Task & Finish Group meeting monthly 5)Timeline agreed with TDA 6)QGAF assessment carried out and action plan in place Potential Sources of Assurance (documented evidence of controls effectiveness) 1)BGAF action plan and self-assessment completed 2)LTFM agreed by the Board 3)FT Project board 4)FT Project plan 5)Integrated Business Plan 6)Public Consultation completed with positive outcome 7)QGAF External assessment completed with implementation of action plan 8)Speciality deep dives to inform Trust on readiness for assessments 9) TDA Readiness Review completed 10) Chief Inspector of Hospitals Inspection 11) Elections to Shadow Council of Governors due following TDA approval 12) TDA Board to Board completed 13) Implementation of Board Development Programme

Director responsible

Director of Corporate Affairs

Initial Risk Current rating

S4 x L2 = 8 S4 x L2 = 8

Target risk score

S4 x L1 = 4

Linked to Risk

1531

Gaps in Control No significant gaps in control identified

Actual Assurances: Positive (+) or Negative (-) Positive (+) Active FT Project Board (+) Draft IBP submitted to TDA 20.6.04 - updated & submitted 20.10.14 (+) LTFM submitted to TDA – 20.06.14 - updated & submitted 20.10.14 (+) FT membership strategy revised and being implemented – achieved 70% of target (+) External review of BGAF & QGAF undertaken (+) BGAF action plan being implemented - Amber/Green (+) Refresh of QGAF by Deloitte’s – complete – score 3.5 action plan in place (+) Readiness Review held with TDA – March 14 (+) FT Timeline agreed with TDA (+) Mock board to board undertaken – Sept 14 (+) Board to Board with TDA took place on 20.11.14 – formal outcome awaited (+) Positive outcome of public and staff consultation (+) Patient & Public membership increasing with engagement of MES (+) Governor Awareness Sessions taking place with +70 expressions of interest (+) Engagement of ERS for Governor Election Services – Draft election timetable agreed (+) Monitor pre-assessment currently in progress

Gaps in assurance Historical Due Diligence to be confirmed by TDA & Monitor Mitigating actions underway 1) Membership Strategy implementation with positive increase in membership 2) Re-fresh of QGAF external assessment - score of 3.5. Action plan being implemented GFM 06/02/15 Update by Date discussed at Board Page 23

Assurance Level gained: RAG Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Ongoing 2) Plans are on track To be discussed at February Board

Objective 5 – Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference

Key Action for 2013/14 objectives and description of any potential significant risk to this priority

5.F. Ensure IT support/optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication 5. F. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems

Controls in place (to manage the risk) 1) IT Strategy aligned with Clinical Strategy and IBP and reviewed Oct 14 2) Clinical Informatics Group 3) Clinical IT leads 4) EPR User Group now well established 5) Various project group (EPMA etc.) 6) Internal Audit 7) EPR costs identified in LTM 8) CCIO and CNIO roles being implemented – greater clinical buy-in 9) EPR Contract now signed and implementation underway with datacenter transfer scheduled for Mid-June 2015 Potential Sources of Assurance (documented evidence of controls effectiveness) Efficiencies being delivered through IT enabled change

Gaps in assurance Trust position known, no identified gaps in assurance

Director responsible

Director of Information and Facilities

Initial Risk

S5 x L3 = 15

Current rating

S5 x L3 = 15

Target risk score

S5 x L2 = 10

Linked to Risk

1605

Gaps in Control 1) Investment in Infrastructure needs to keep pace with organization requirements 2) Insufficient focus on change benefits realization due to financial constraints 3) Lack of operational involvement in identifying and delivering benefits 4) Insufficient focus on staff training 5) Need for increased operational manager buy-in

Actual Assurances: Positive (+) or Negative (-) Positive (+) Improving infrastructure (e.g. Wi-Fi) (+) Development of existing EPR platform (e.g. EPMA) (+) EPR Contract signed (+) Successful EPMA upgrade Negative (-) Major IT transition approaching – 2015 (-) Technical issues resulting in organizational disruption from a recent major IT implementation, has led to concerns over future implementations Assurance Level gained: RAG

Mitigating actions underway 1. Procurement of replacement EPR as national contract ending November 2015 - preferred supplier now reached and OBC agreed by Board and TDA 2. Establishment of Clinical Lead IT Role 3. Clinical Cerner User Group now in place with strong leadership 4. Greater focus on IT in Capital Plan for 2014/15 and future years 5. Introduction of Business Continuity System for EPR (7/24) Update by Page 24

IM 12/01/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. EPR Contract to be awarded October 2014 – preferred supplier now selected. EPMA go-live November 2014. 724 Go-live November 2014. PC Upgrade plan in-place, funded and commenced. Network review first draft now complete and action plan being prepared. To be discussed at February Board

18/11/2014

22/09/2014 21/05/2014 26/07/2013 25/09/2013 26/07/2013

i) Follow up notification to CCGs and agree payment from the 70% (ongoing)

16 4

16 Robust plan required to manage elective activity 30/05/2014 As described on the BAF 31/03/2015

Involvement of Service Users

Failure to maintain Emergency Department performance

Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care.

1) EDD Patient Pathway 2) Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches on weekly to implement lessons learnt

20 4

16 As described on the board assurance framework

31/03/2015

If the Trust does not maintain and improve ability to allocate Patient admitted to the the right bed first time there is an increased risk of receiving poor quality of our care (effectiveness, experience and safety) right bed first time

15 As described on BAF

31/03/2015

31/03/2014

If non elective activity does not reduce there will be constraints i) Ring fence elective beds after new capacity has opened and monitor delivery. Risk that demand growth on capacity to deliver the demand plan. activity does not deliver the Subset of BAF 5.A.1 plan

16 4

16 As described on BAF

31/03/2015

20/11/2014

Failure to stop Risk of overspending from operational pressures. divisional overspending against budget

16 4

16 As described on the BAF

31/03/2015

i) Divisions to implement action plans and contingencies to control/or recover overspending. Specific action is required in all Divisions. iii) Agency PMO to deliver outputs in respect of reduced agency usage following recruitment. The October milestone was not achieved in the face of the increased capacity required. Position being reviewed (Nov).

31/03/2015 31/03/2015 31/03/2015

1) Operational meeting three times a day chaired by Chief / Deputy Chief Operating Officer with clinical involvement from Matrons, Nurse Specialists and therapists 2) Daily Board rounds by clinical site team 3) Live 'To come In' lists available to view in all specialty wards to encourage active pull of patients from AMU to the correct specialty bed 4)Matrons walk round 5) Additional screens arriving to reduce chance of mixed sex accommodation breaches during winter pressures 6) Matron on site 7 days a week

31/03/2015

Financial Management

Risk that the Trust may not achieve its breakeven plan as a result of non elective activity no reducing as planned and no payment received in respect of the marginal tariff. Subset of BAF 5.A.1

Financial Management

Next Review

Done date 06/12/2013 26/07/2013 26/07/2013 02/09/2013 11/02/2014 06/12/2013

Residual Rating

Current Rating

Due date 31/03/2013 30/06/2013 01/04/2013 02/09/2013 31/03/2014 31/03/2013 20/03/2015 01/03/2015 22/09/2014 31/03/2014 30/03/2013 25/09/2013 31/01/2013

Involvement of Service Users

Treatment Plan 15 Develop RAG rated system for terminal cleaning Audit terminal cleaning Implement ATP testing Dedicated internal norovirus planning meeting. Use of red aprons during outbreaks of D&V Meeting with stakeholders regarding norovirus preparedness Audit of post-outbreak cleaning Pilot Patient Hand Hygiene Champions in Elderly Care Stakeholders meeting to discuss health system norovius planning Monitor use of ED risk assessment for patients admitted with diarrhoea and/or vomiting Monitor ward refurbishment programme Stakeholder norovirus study day Prepare options appraisal for emptying bays to facilitate terminal cleaning following outbreak

31/03/2015

16 3

Current Likelihood

Current Consequence

Initial Rating

Existing controls D&V policy Hydrogen peroxide system for terminal cleaning Use of Actichlor Plus for environmental cleaning Use of Tristel Jet for commode and bed pan cleaning Use of SEC Norovirus Toolkit Outbreak control Group Surveillance of diarrhoea and vomiting Red aprons system Stat and mandatory training Policy Communications messages to staff, visitors and patients Norovirus leaflets Hand hygiene facilities Restricted visiting Use of signs at entrance to wards and bays, and red aprons to facilitate communication that an outbreak is taking place.

Patient Safety

Risk Type

Description Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on patient safety and trust reputation. Has operational impact due to bed closures.

Risk that non elective does not reduce and no payment in respect of marginal tariff

Financial Management

Risk Owner Des Holden Paul Simpson Paul Bostock Paul Bostock Paul Simpson Paul Simpson

Specialty Medical Director's Office Finance - Fin. Management Operations Operations Finance - Fin. Management Finance - Fin. Management

Directorate CORP CORP CORP CORP CORP CORP

Open Date 23/01/2013 23/07/2013 29/08/2013 19/09/2013 18/06/2014 18/06/2014

Monitoring Committee Safety Executive Committee Responsiveness Responsiveness Executive Committee Executive Committee

ID 1401 1480 1491 1501 1601 1602

Title Risk of outbreak of viral gastroenteritis

15 As described on the BAF

31/03/2015

1.IT Strategy aligned with Clinical Strategy and IBP 2.Clinical Informatics Group 3.Clinical IT leads 4.EPR User Group 5.Various project group (EPMA etc.) 6.Internal Audit 7.EPR costs identified in LTM

15 5

15 As described on the BAF

31/03/2015

15 5

The current local availability of qualified nurses and pressures on temporary staffing costs is effecting the Trust's ability to

The Trusts current vacancy rates, turnover and reliance on agency is leading to increased resource time being spent on ensuring existing clinical areas are safely staffed. The acute presentation of these issues is felt in the management of escalation areas and plans to staff the decant ward.

As described on the BAF

16 4

16 As described on the BAF

31/03/2015

Increasing Sickness Absence Levels with impact on day to day management and expenditure

Continuing risk to the delivery of effective services and Trust Strategic Objectives caused by the resources required to actively manage the Trusts rising Sickness Absence rate and ensure safe services. This is also having a significant effect on the ability to control the Trusts temporary staffing costs.

Firstcare real time sickness absence monitoring reports and daily updates to managers inbox. Daily sit reps at ward level used to ensure shift by shift safe levels of service. eRostering software to manage rota's prospectively. Agency PMO.

15 3

15 Actions described in the Agency PMO Focused interventions to support the Trust's Stress Management Policy (Anxiety/Stress/Depression has been highest reason for absence for past 8 months)

31/03/2015 31/08/2015

9 01/04/2015

31/03/2015

ICT Infrastructure

Financial Management

1) Bi weekly review of forward cash flow by finance team and CFO 2) Cash and working capital policy and strategy 3) Annual cash plan linked to business plan and capital plan

Staffing - general

Risk of not being able to pay suppliers from in sufficient cash due to poor liquidity problem

There is a risk As described on the BAF that the Trust will not fully realise the benefits available from well embedded IT systems

Staffing - general

Paul Simpson Ian Mackenzie Fiona Allsop Yvonne Parker

Finance - Fin. Management Bus. Int. - Information & Data Quality Operations HR - Workforce

CORP CORP CORP CORP

18/06/2014 18/06/2014 23/10/2014 01/02/2015

Executive Committee Executive Committee Workforce Workforce

1604 1605 1652 1672

Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position

TRUST BOARD IN PUBLIC

Date: 26th February 2015 Agenda Item: 2.2

REPORT TITLE:

Chief Nurse & Medical Director Report

EXECUTIVE SPONSOR:

Fiona Allsop, Chief Nurse Des Holden, Medical Director Sally Brittain, Deputy Chief Nurse Barbara Bray, Deputy Medical Director

REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

N/A

Action Required: Approval

Discussion

Assurance (√)

Purpose of Report: An update of on-going work in relation to safe and quality patient care that sits out with the operational performance reports including Monthly Safer Staffing information and exemption report.

Summary of key issues  

Safe Staffing Report (January 2015) Patient Safety Executive meetings

Recommendation: The Trust Board is asked to review and gain assurance from the information within the report Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact

yes

Financial impact

yes

Patient Experience/Engagement

yes

Risk & Performance Management

yes

NHS Constitution/Equality & Diversity/Communication

yes

Attachment:

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 26TH February 2015 CHIEF NURSE AND MEDICAL DIRECTORS’ REPORT 1.

Introduction

This report seeks to provide regular assurance and information to the Trust Board in response to national and local policy and care changes which impact patient safety, experience and clinical outcomes. 2.

Safe Staffing Compliance

Safe staffing data for the Trust was uploaded to unify as required and is now visible to the public via the NHS Choices and the Trust Website. The data is presented for the Trust Board within the table below. RN compliance of 94.76% during the day and 92.63% at night indicates a reduction in compliance against last month and is expected given the difficulty filling shifts which the Trust has experienced in January 2015 with escalation beds open and the opening of Capel Annex. During the day the wards were supported by the senior nursing team such as Matrons, Clinical Specialist Nurses and Divisional Chief Nurses for support and guidance. At night the enhanced site, and outreach teams provided support to the wards. Data Capture Results – Monthly (January 2015) Day

Night

Average fill rate – registered nurses/midwives (%)

Average fill rate – care staff (%)

Average fill rate – registered nurses/midwives (%)

Average fill rate – care staff (%)

Abinger Ward

93.53%

97.84%

100%

Acute Medical Unit

94.8%

85.27%

99.08%

91.13%

Birthing Centre

100%

N/A

Bletchingley Ward

97.54%

100.65%

99.34%

100%

Brockham Ward

97.04%

96.65%

100%

92.68%

Brook Ward

98.95%

94.66%

96.77%

N/A

Buckland Ward

97.74%

91.26%

100%

Ward

3 An Associated University Hospital of Brighton and Sussex Medical School

Burstow Ward

94.35%

100%

95.16%

Capel Annex l Ward

97.58%

95.22%

101.61%

104.84%

Capel Ward

84.83%

104.4%

92.47%

100%

Chaldon Ward

96.27%

93.46%

95.45%

99.29%

Charlwood Ward

98.12%

93.77%

98.39%

Copthorne Ward

100%

98.39%

100%

Coronary Care Unit

91.53%

155.07%

100%

96.77%

100%

93.55%

100%

95.16%

Discharge Lounge

85.03%

91.11%

87.1%

93.55%

Godstone Ward (Haem)

98.32%

715.22%

100%

N/A

Godstone Ward (Med)

40.78%

40.47%

50%

39.24%

Holmwood Ward

98.06%

98.31%

98.39%

100%

ITU / HDU

96.63%

75.94%

97.51%

80%

Leigh Ward

94.96%

97.72%

100%

91.94%

Meadvale Ward

91.74%

91.13%

98.39%

98.44%

Neonatal Unit

97.49%

91.38%

99.14%

83.33%

Newdigate Ward

96.17%

86.96%

91.94%

87.1%

Nutfield Ward

99.58%

93.67%

98.39%

100%

Delivery Suite

4 An Associated University Hospital of Brighton and Sussex Medical School

Outwood Ward

95.59%

91.55%

100%

69.23%

100%

N/A

Surgical Assessment Unit

97.58%

93.55%

100%

85.48%

Tandridge Ward

96.94%

99.65%

100%

98.33%

Tilgate Ward

98.63%

96.08%

100%

Woodland Ward

97.66%

88.37%

93.55%

Total

94.76%

92.63%

97.22%

93.29%

Rusper Ward

3. Patient Safety Executive meetings This year the Trust has commenced a weekly meeting of clinical and non-clinical managers for 20 minutes to discuss patient safety issues and ensure that the learning is disseminated throughout the organisation. The safety issue, based on a patient story, serious incident review or audit of practice is presented by a clinician and discussion encouraged. So far the sessions have varied from an audit of emergency management of patients with severe sepsis to the management of patients at risk of C Difficile. The sessions are well attended and the feedback so far is very positive.

5 An Associated University Hospital of Brighton and Sussex Medical School

Date: 26 February 2015

TRUST BOARD IN PUBLIC

Agenda Item: 2.2 Appendix REPORT TITLE:

Right Staffing Review – Current Position for Nursing and Midwifery

EXECUTIVE SPONSOR:

Fiona Allsop, Chief Nurse

REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Fiona Allsop, Chief Nurse Sally Brittain, Deputy Chief Nurse Board reports - December 2013, January 2014, March 2014, June 2014, November 2014 Monthly updates to Board from June 2014

Action Required: Approval ()

Discussion (√)

Assurance (√)

Purpose of Report: To update the board on the current position in relation to achieving the registered nursing ratio uplift agreed in April 2014. Summary of key issues In April 2014 the Board agreed that the Trust would enact the following nursing and midwifery staffing ratios to meet the staffing capacity and capability requirements outlined in the National Quality Board paper - How to ensure the right people, with the right skills, are in the right place at the right time, published in November 2013. The staffing profile agreed for general wards was a minimum ratio of 1 registered nurse to 7 patients during the day and 1 registered nurse to 10 patients at night. The agreed registered to unregistered split was 65:35. This profile was planned to be enacted over an 18 month period from November 2014. Progress has been made in delivery against this plan but the Trust has been unable to recruit sufficient registered nurses to deliver the 1:10 ratio at night. It is anticipated that this will be delivered through the summer of 2015. Recommendation: 1. That the Board note the current status and the recruitment plan, notably Philippines recruitment. 2. That the Board continue to monitor the monthly planned versus actual staffing and other related patient safety and workforce indicators to obtain assurance on the Trust quality profile. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health 1

An Associated University Hospital of Brighton and Sussex Medical School

economy SO3: Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about SO4: Responsive â&#x20AC;&#x201C; Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

Yes â&#x20AC;&#x201C; national requirement to report planned versus actual nursing staffing for general ward areas Potential if Trust unable to recruit permanent registered nursing staff. Yes as improved nursing ratios should improve patient experience Potential reputational risk to organisation if unable to recruit sufficient permanent registered nursing staff to meet plan Potential reputational risk to organisation if unable to recruit sufficient permanent registered nursing staff to meet plan

Attachment:

An Associated University Hospital of Brighton and Sussex Medical School

Right Staffing Review â&#x20AC;&#x201C; Guidance and Current Position for Nursing and Midwifery February 2015 Summary In April 2014 the Board agreed that the Trust would enact the following nursing and midwifery staffing ratios to meet the staffing capacity and capability requirements outlined in the National Quality Board paper - How to ensure the right people, with the right skills, are in the right place at the right time, published in November 2013. The staffing profile agreed for general wards was a minimum ratio of 1 registered nurse to 7 patients during the day and 1 registered nurse to 10 patients at night. The agreed registered to unregistered split was 65:35. This profile was planned to be enacted over an 18 month period from November 2014. Progress has been made in delivery against this plan but the Trust has been unable to recruit sufficient registered nurses to deliver the 1:10 ratio at night. It is anticipated that this will be delivered through the summer of 2015. Discussion As previously discussed at the Board the ward configuration at SaSH indicates that a 1:7 ratio is optimal and has been used as the base for day time staffing. At night a figure of 1:10 has been determined as a first step from which the organisation will transition to 1:7. The senior ward sisters in the Trust are generally delivering direct clinical care coordination 50% of the time with the remaining time being used for managerial activities. They are supported by nine clinically based matrons in the medical and surgical divisions. There is limited direct educational or practice development support in the general ward areas. Following the decision taken at Board in April 2014 detailed work has been undertaken to support nursing recruitment and retention to meet known existing turnover and deliver the increased nursing ratios agreed. As the Board is aware from subsequent discussions, notably around approval to undertake international recruitment during the spring of 2015, the Trust has been successful at meeting the challenge presented by nursing turnover but significant challenges remain in meeting the uplift required to meet the revised staffing ratios by October 2015. For the maternity service there was an agreement to recruit an additional 10 midwives in two cohorts. The first cohort of 5 midwives has been recruited and the second cohort is being recruited currently. The Safer Nursing Care Tool (SNCT) for measuring nursing acuity and dependency will be run again for the general wards in March 2015 as part of the requirement to review staffing on a six-monthly basis. The Birthrate plus tool will also be run for maternity services and emergency nursing staffing levels are in the process of being reviewed against the recent NICE draft guidance. The results of these reviews will be shared with the Board in May/June 2015. Fiona Allsop Chief Nurse 3

An Associated University Hospital of Brighton and Sussex Medical School

Date: 26th February 2015

TRUST BOARD IN PUBLIC

Agenda Item: 2.3 Safety & Quality Committee Update

REPORT TITLE:

Richard Shaw, Chair Safety & Quality Committee Richard Shaw, Chair Safety & Quality Committee

EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

n/a

Action Required: Approval ()

Discussion ( )

Assurance (ď&#x192;ź)

Purpose of Report: To provide an update of the activities of the safety and quality committee. Summary of key issues The report provides a summary of the key agenda items which were discussed at the Safety and Quality Committee in January 2015. Recommendation: N/A Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about Corporate Impact Assessment: Legal and regulatory impact

Compliance with CQC, MHRA and Audit Commission

Financial impact

Serious incidents often become claims

Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication Attachment:

Reporting, investigation and learning from serious incidents informs risk management

Trust Board Report Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 5th February. It considered its standing agenda items; the report from January’s ECQRM and CQRM meeting and the SQC Dashboard and Quality Report. The committee noted that while winter pressures subsided somewhat in January, the high numbers presenting at A&E over Christmas and New Year had impacted adversely on services such as fractured neck of femur, stroke, and paediatrics as well as on cancellation of elective operations. The Committee heard that an assessment of pressures had taken place with the intention of reporting the finding to the next Board meeting, and asked for these impacts to be included in the report. The Committee sought assurance about adverse patient experience comments posted on the Patient Opinion website relating to care in the maternity unit and asked for the comments and subsequent actions to be drawn to the attention of Chiefs and Directors. CQRM met on 20th January and received a brief update on the CCG actions to address the CQC action plan. However, no action plan had yet been provided. The presentation on stroke made to SQC in January was shared at the CQRM meeting. It was emphasized that further improvements were being held back by pressure on beds and delayed discharges. Concern was expressed at report the may cut back further on discharge services, and the Committee asked to be kept informed about this risk. Delayed Discharge The Committee requested an update on the government initiative to achieve a 50% reduction in delayed discharges over the course of February. The Trust was involved because of its high numbers of patients medically fit for discharge – some 113 on the day before the committee meeting, equivalent to four wards. Early signs were that the average length of stay was beginning to reduce but that overall numbers had not yet seen much change. There was a drive to procure more private nursing home capacity, although this was generally more expensive. Infection Control The Committee received a half-yearly report on infection control. It congratulated staff on achieving no MRSA blood stream infections over more than 365 days. Orthopeadic infections have also reduced sharply. There had been 17 cases of Clostridium difficile by 3rd February, against a maximum annual target of 29 by end March, meaning that the Trust remains below trajectory. However, it was noted that the target for 2015/16 will be reduced to 15, with the potential for fines where the target is exceeded and there are lapses in care. The Committee therefore asked for a review of our practice against national guidance to support the further reductions required. The Committee also asked for an update in two months’ time from the Cerner User Group of actions to improve identification of patients with biohazards. CQUIN The Committee welcomed the good progress being made in achieving CQUIN targets for the current year and noted that targets for next year are yet to be agreed. Incident Report The Committee was pleased to see an improvement in the Trust’s under-reporting of near-miss and no-harm incidents, while the number of moderate and extreme incidents remained stable. The Committee asked for data from previous years to be incorporated in future reports, where possible, to enable it to take a longer term perspective of trends.

The next meeting of the Committee is on 5th March.

Integrated Performance Report M10 â&#x20AC;&#x201C; January 2014

Presented by: Paul Bostock (Chief Operating Officer) Des Holden (Medical Director) Paul Simpson (Chief Financial Officer)

An University HospitalHospital of AnAssociated Associated University of Brighton andand Sussex Medical School School Brighton Sussex Medical

Performance – January 2014 Care Quality Commission • The Trust is not subject to any CQC enforcement action and continues to progress the improvement plans which followed the CQC Inspection in May 2014. Patient Safety • Patient safety indicators continued to show expected levels of performance. • The Trust had no MRSA bloodstream infections and two Trust acquired C-Diff cases in January 2015. • Adult bed occupancy remains higher than plan due to increased activity and is one of the items covered within the collaborative CQC action plan. Clinical Effectiveness • The latest HSMR data shows overall Trust mortality is lower than expected for our patient group. • Maternity indicators continue to show expected performance. Access and Responsiveness • In January 2015, 92% of patients were admitted or discharged within the ED standard of 4 hours with no 12 hour trolley wait breaches. • The Admitted and Incompletes RTT standards were achieved in January 2015. There were a number of speciality failures as work is undertaken to reduce the number of patients waiting over 18 weeks for treatment. • All Cancer Access Standards were achieved. Patient Experience • In January 2015, ED and Inpatients both achieved an FFT score of 96%.

An Associated University Hospital of Brighton and Sussex Medical School 2

Performance – January 2014 Workforce • The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place. Ward staffing levels are now published on the Trust’s external website at ward level. The Trust is also continuing to monitor temporary staffing usage on a weekly basis Finance • The Trust is still on plan at M10 with a £1.9m surplus year to date Key Risks • Finance – The risk to the forecast outturn is recorded as £5.5m potential adverse change. That risk is from income (emergency activity over plan / reduced elective) and divisional overspending. • Quality – The Significant Risk Register for the Trust includes five quality risks in relation to “Right bed first time”, ED Access standards, Outbreak of viral gastroenteritis, Local availability of qualified nurses and Increasing sickness absence levels.

Action: The Board are asked to note and accept this report Legal:

What are the legal considerations & implications linked to this item? Please name relevant Act

Regulation:

What aspect of regulation applies and what are the outcome implications? This applies to any regulatory body.

Patient safety: Legal actions from unintentional harm to patients would normally be covered by negligence, an area of English tort (civil) law, providing the remedy of compensation. Case law is extensive. Criminal action could be pursued if investigation judged intentional harm and remedies will vary according to severity. Staff safety: The Health and Safety at Work Act etc 1974 may apply in respect of employee health and safety or non clinical risk to patients (usually reported under the Reporting of Injuries Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995) The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore license care services under the Health and Social Care Act 2009 and associated regulations. The health and safety executive regulates compliance with health and safety law. A raft of other regulators deal with safety of medicines, medical devices and other aspects.

An Associated University Hospital of Brighton and Sussex Medical School 3

Patient Safety Patient Safety Indicator Description

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Jan‐15

No of Never Events in month

No of medication errors causing Severe Harm or Death

Safety Thermometer ‐ % of patients with harm free care (all harm)

90.4%

92.7%

94.2%

90.5%

92.8%

92.3%

90.8%

92.5%

92.0%

95.0%

93.0%

Safety Thermometer ‐ % of patients with harm free care (new harm)

94.2%

96.5%

97.7%

95.4%

97.0%

97.3%

95.3%

96.1%

94.5%

98.0%

96.0%

97.0%

96.0%

Percentage of patients who have a VTE risk assessment

96%

95%

96%

95%

WHO Checklist Usage ‐ % Compliance

100%

98%

100%

0.29

0.13

0.35

0.24

0.40

0.06

0.63

0.17

0.12

0.11

0.28

Number of Sis Serious Incidents ‐ No per 1000 Bed Days Number of overdue CAS and NPSA alerts

Trend

• Patient safety indicators continue to show expected levels of performance. • There were no Never Events or medication errors causing severe harm or death in January 2015. • Safety Thermometer – achievement of both the “All Harm” and “New Harm” measures was sustained in January 2015. • VTE assessment performance was achieved in January 2015.

An Associated University Hospital of Brighton and Sussex Medical School 4

Patient Safety • Five SIs were declared in January 2015. • A child with meningitis had CT scan but a diagnosis was missed, resulting in a delay of 24 hours before transfer for neurosurgical intervention. In the meantime she had deteriorated and developed a hemiplegia. • 2 x Patient fall in resulting a fracture neck of femur • CDiff cross infection • Closure of the maternity unit 24/10/14 (reported in line with the South of England maternity trigger list at the request of NHS England) Infection Control Indicator Description

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Jan‐15

MRSA (incidences in month)

CDiff Incidences (in month)

MSSA

E‐Coli

Trend

• There were no cases of MRSA in January 2014, and two cases of trust acquired C.diff taking the total to 17 YTD against a trajectory of 24 YTD and 23 cases for the same period last year. • The trust continues to enforce good antimicrobial practice with on-going audit and reporting of results to clinical teams. • In light of the recent outbreaks of viral gastroenteritis, the following risk has been added to the Trust's significant risk register: • Risk of outbreak of viral gastroenteritis - Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on patient safety and experience – Risk score 15 (Likelihood of 5 and consequence of 3)

An Associated University Hospital of Brighton and Sussex Medical School 5

Clinical Effectiveness Mortality and Readmissions Indicator Description

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

HSMR (56 Monitored diagnoses ‐ 12 Months)

97.5

98.3

94.9

95.3

95.6

93.7

92.9

91.5

90.2

88.6

Emergency readmissions within 30 days (PBR Rules)

7.0%

6.3%

7.4%

6.7%

6.6%

7.2%

6.8%

7.1%

Nov‐14

Dec‐14

7.0%

6.9%

Jan‐15

Trend

• Mortality – The latest HSMR data shows overall Trust mortality is lower than expected for our patient group when benchmarked against national comparators. • Readmissions within 30 days continues to remain at expected levels. Maternity Indicator Description

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Jan‐15

C Section Rate ‐ Emergency

19%

20%

16%

18%

15%

14%

17%

14%

17%

12%

14%

17%

19%

C Section Rate ‐ Elective

10%

11%

10%

11%

10%

13%

12%

13%

11%

5.2%

6.0%

6.2%

7.6%

6.7%

7.5%

8.5%

6.1%

8.0%

5.4%

3.8%

6.3%

6.0%

Maternal Deaths Admissions of full term babies to neo‐natal care

Trend

• Maternity continues to show positive performance overall and quality measures remain under monitoring at the Clinical Effectiveness committee.

An Associated University Hospital of Brighton and Sussex Medical School 6

Access and Responsiveness Emergency Department Indicator Description

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Jan‐15

95.7%

94.7%

97.5%

96.8%

96.1%

96.6%

97.6%

95.9%

95.4%

94.3%

95.7%

93.3%

92.0%

Patients Waiting in ED for over 12 hours following DTA

Ambulance Turnaround ‐ Number Over 30 mins

105

151

183

344

Ambulance Turnaround ‐ Number Over 60 mins

ED 95% in 4 hours

Trend

• In January 2015, 92% of patients were admitted or discharged within 4 hours with no 12 hour trolley wait breaches • The delivery of the ED 4hr standard remains a challenge across the country and despite the under-performance at the Trust, we remain one of the best performing Trusts in the country. • Ambulance Turnaround data is still subject to review with SECAmb. • In light of the on-going operational pressures in the Trust, the following two risks are on the significant risk register: • ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system to manage winter pressures – Risk score 16 (Likelihood of 4 and consequence of 4) • Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed first time, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5 and consequence of 3)

An Associated University Hospital of Brighton and Sussex Medical School 7

Access and Responsiveness Cancer Indicator Description

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Jan‐15

Cancer ‐ TWR

94.5%

95.9%

96.1%

93.1%

93.6%

93.1%

93.0%

93.2%

93.8%

93.1%

Cancer ‐ TWR Breast Symptomatic

93.3%

99.2%

98.6%

93.7%

93.5%

93.7%

93.2%

94.4%

93.2%

93.3%

93.6%

93.5%

93.4%

Cancer ‐ 31 Day Second or Subsequent Treatment (SURGERY)

100.0%

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer ‐ 31 Day Second or Subsequent Treatment (DRUG)

100.0%

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer ‐ 31 Day Diagnosis to Treatment

96.8%

99.0%

100.0%

98.1%

99.2%

97.1%

99.2%

100.0%

99.1%

98.4%

97.1%

Cancer ‐ 62 Day Referral to Treatment Standard

87.8%

85.0%

95.2%

89.7%

87.0%

86.9%

90.8%

87.9%

78.8%

87.1%

86.3%

86.1%

85.4%

Cancer ‐ 62 Day Referral to Treatment Screening

25.0%

50.0%

100.0%

50.0%

100.0%

83.3%

100.0% 100.0%

92.3%

Trend

• All Cancer Access Standards were achieved in January 2015.

An Associated University Hospital of Brighton and Sussex Medical School 8

Access and Responsiveness Referral to Treatment (RTT) and Diagnostics Indicator Description

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Jan‐15

RTT Admitted ‐ 90% in 18 weeks

93.4%

92.0%

91.4%

92.9%

94.4%

94.7%

92.8%

90.4%

90.7%

88.1%

81.4%

91.1%

90.2%

RTT Non Admitted ‐ 95% in 18 weeks

98.1%

97.6%

97.4%

97.2%

96.5%

95.2%

95.8%

93.2%

93.9%

92.8%

95.0%

91.7%

RTT Incomplete Pathways ‐ % under 18 weeks

96.2%

95.9%

96.2%

96.4%

96.0%

95.2%

94.9%

93.9%

93.8%

93.5%

93.3%

92.2%

92.1%

Percentage of patients w aiting 6 weeks or more for diagnostic

0.1%

0.0%

0.3%

0.1%

0.0%

0.4%

0.1%

0.9%

% of operations cancelled on the day not treated within 28 days

1.3%

0.0%

1.0%

1.6%

0.0%

RTT Patients over 52 weeks on incomplete pathways

Trend

• In January 2014, the admitted and incomplete pathways RTT standards were achieved at aggregate level while the non-admitted standard was not achieved. • There were a number of speciality failures of the admitted and non-admitted standards as work is undertaken to reduce the number of patients waiting over 18 weeks for treatment. Several specialities also failed the incompletes standard. • Within Diagnostics, the quality standard for waits over 6 weeks was achieved and there were no urgent operations cancelled twice.

An Associated University Hospital of Brighton and Sussex Medical School 9

Patient Experience Patient Voice Indicator Description

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Jan‐15

Inpatient FFT ‐ % positive responses

98%

96%

97%

95%

96%

Emergency Department FFT ‐ % positive responses

99%

98%

95%

96%

93%

96%

Maternity FFT ‐ Antenatal ‐ % positive responses

97%

99%

96%

97%

95%

90%

98%

100%

98%

95%

93%

100%

96%

Maternity FFT ‐ Postnatal Ward ‐ % positive responses

92%

93%

90%

92%

96%

86%

Maternity FFT ‐ Postnatal Community Care ‐ % positive responses

93%

100%

94%

100%

85%

100%

Maternity FFT ‐ Delivery ‐ % positive responses

Mixed Sex Breaches

Complaints (rate per 10,000 occupied bed days)

Trend

December FFT Scores • ED achieved an FFT score of 96%, an increases of 3% compared to November. The response rate was 24%. • At 96% the inpatient score increased to nearer that seen in previous months. The response rate increased from 31% to 34% • In maternity, FFT scores increased for both Antenatal and the Postnatal Community Care (to 98% and 100% respectively), but dropped for both the Delivery and Postnatal Ward touchpoints. • For the postnatal community touchpoint the FFT response rate remains a challenge with only 3% of mothers responding. • There were no Mixed Sex Breaches in January 2015.

An Associated University Hospital of Brighton and Sussex Medical School 10

Workforce Workforce Indicator Description

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Jan‐15

Average fill rate – registered nurses/midwives (%) ‐ Day

97.3%

97.7%

97.5%

95.7%

95.4%

96.4%

97.1%

95.1%

94.8%

Average fill rate – care staff (%) ‐ Day

95.6%

97.3%

95.1%

97.5%

96.4%

95.3%

95.0%

93.1%

92.6%

Average fill rate – registered nurses/midwives (%) ‐ Night

97.5%

97.9%

98.2%

97.2%

98.1%

99.2%

99.4%

97.3%

97.2%

Average fill rate – care staff (%) ‐ Night

96.7%

97.5%

97.2%

97.5%

96.7%

97.4%

95.3%

93.7%

93.3%

Overall Sickness Rate

3.9%

3.2%

3.0%

3.3%

3.6%

3.8%

3.2%

4.0%

4.4%

4.0%

4.5%

4.3%

%age of staff who have had appraisal in last 12 months

83%

76%

87%

80%

82%

80%

75%

74%

72%

69%

72%

67%

14.5%

14.8%

14.3%

14.6%

14.5%

15.0%

15.8%

15.6%

15.3%

15.6%

15.7%

Staff Turnover rate

Trend

• The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place. • Staff Turnover increased marginally to 15.7% in January 2015. HR Business Partners within the divisions continue to support actions to improve recruitment and retention with a significant focus on nursing. • Sickness absence decreased to 4.3% in January 2015. • The following workforce related risks sit on the Trust’s significant risk register: • Current local availability of qualified nurses and pressures on temporary staffing is leading to increased resource time being spent on ensuring existing clinical areas are safely staffed – Risk score 16 (Likelihood of 4 and consequence of 4) • Increasing Sickness Absence Levels with impact on day to day management and expenditure – Risk score 15 (Likelihood of 5 and consequence of 3)

An Associated University Hospital of Brighton and Sussex Medical School 11

Finance Indicator Description

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐14

Aug‐14

Sep‐14

Oct‐14

Nov‐14

Dec‐14

Jan‐15

Outturn £m Surplus / (Deficit) ‐ Plan

0.0

2.3

Outturn £m Surplus / (Deficit) ‐ Forecast

0.3

2.3

YTD £m Surplus / (Deficit) ‐ Plan

0.0

(0.9)

(1.7)

(2.8)

(2.1)

(1.5)

(1.3)

0.1

0.4

1.0

1.9

YTD £m Surplus / (Deficit) ‐ Actual

0.3

(0.9)

(1.7)

(2.8)

(2.1)

(1.5)

(1.3)

0.1

0.5

1.0

1.9

Outturn UNDERLYING £m Surplus / (Deficit) ‐ Plan

(3.5)

3.4

Outturn UNDERLYING £m Surplus / (Deficit) ‐ Actual

(4.3)

3.4

1.0

(0.7)

(5.2)

8.7

9.9

11.1

0.4

0.6

1.1

1.9

2.8

3.8

5.0

6.2

7.4

8.6

(5.5)

(4.3)

0.0

(8.5)

(8.0)

(8.5)

(6.3)

(5.5)

Outturn Cash position £m Fav / (Adv) ‐ Forecast

2.6

YTD Cash position £m Fav / (Adv) ‐ Actual

3.8

8.3

2.6

2.9

2.6

2.4

2.7

3.1

3.0

3.8

2.8

4.8

3.8

YTD Liquid ratio ‐ days

(1.0)

(13.0)

(16.0)

(15.0)

(18.0)

(17.0)

(10.0)

(7.0)

(4.0)

(8.0)

YTD BPPC (overall) volume £m

84%

85%

94%

90%

85%

88%

87%

YTD BPPC (overall) value £m

84%

85%

87%

89%

90%

87%

88%

87%

92%

78%

84%

83%

Outturn Capital spend Fav / (Adv) ‐ forecast

16.4

19.3

19.4

19.3

YTD Savings £m ‐ Actual OT Risk £m Surplus / (Deficit) ‐ Assessment

• The Trust is still on plan at M10 with a £1.9m surplus year to date. • Divisions continue to spend higher than budget, however, as expected this is offset by income and the Trust is still within forecast despite levels of emergency activity within the Trust peaking in December, and remaining high in January. • As reported in previous months, the year to date income includes an accrual in respect of challenge to CCGs over the level of emergency activity and the withheld marginal rate, as well as 2 tranches of winter resilience funding (10/12ths has been included for each). • The forecast year end position remains a £2.3m surplus. The risks to this position (mainly from the impact of emergency activity) have been estimated at £5.5m (a reduction against M09). The downside is a risk of a £2.5m deficit. The output from discussions over CCG disputes and marginal rate are the key factors.

An Associated University Hospital of Brighton and Sussex Medical School

Finance • The cost improvement plan year to date target is £8.6m and at M10 this has been achieved. • The underlying position at the end of January is £2.5m deficit, reflecting the non-recurrent funding in the year to date position setting off costs from emergency activity and reduced elective income. The forecast year end underlying position is £5.2m, as reported last month. • The cash balance at the end of January 2014 was £3.8m, below the planned position due to the delay in receiving contract payments from CCGs. The cash position is becoming more challenging as there are delays in agreeing income figures and significant financial challenges from CCGs and as a result, an application for temporary borrowing is being made. • The capital forecast spend has been adjusted to £19.3m (reduction of £100k in respect of Salix funding & expenditure as agreed with TDA).

An Associated University Hospital of Brighton and Sussex Medical School 13

TRUST BOARD IN PUBLIC

Date: Agenda Item:

REPORT TITLE:

CQC Improvement Action Plan

EXECUTIVE SPONSOR:

Sue Jenkins

REPORT AUTHOR (s):

Sue Jenkins

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Executive Committee

Action Required: Approval ()

Discussion ()

Assurance (√)

Purpose of Report: This report provides the Board with assurance that the recommendations made following the CQC visit in May 2014 are being addressed Summary of key issues The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as “good” for all domains. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. In response to the CQC report and summary of findings an action plan has been developed to address the areas for improvement in the outpatient’s service. A monthly update of progress against the action plan is provided to the Trust Board every month. This report provides a summary of progress to date which confirm that all of the four main work streams are rated as green. The CQC also made some “should do” recommendations which will be included in this report on a quarterly basis. The next update on these actions will be received in March 2015. At the last Board meeting a letter was considered from the CCGs providing an update on the system wide issues that were identified at the quality summit. A letter requesting additional detail has been sent to the CCGs in response to this. This report includes an update on the actions agreed by other parties that were recommended at the quality summit.

Recommendation: The Board is asked to consider this report and ensure that it provides assurance around delivery of the CQC improvement plan.

Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory implications Financial implications Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

Compliance with CQC recommendations and delivery of action plan to address areas highlighted is essential Capital and revenue implications will be addressed through separate business cases Feedback from patients regarding their experience in outpatients is a key part of this action plan A monthly steering group is in place to ensure delivery of the plan N/A

Attachment: CQC Improvement action plan – February 2015

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT –26 February 2015 CQC Improvement Plan Update - Outpatients 1.

Introduction

The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as “good” for all domains. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. In response to the CQC report and summary of findings an action plan has been developed to address the areas for improvement in the outpatient’s service. A monthly update of progress against the action plan is provided to the Trust Board every month. This report provides a summary of progress to date which confirm that all of the four main work streams are rated as green. The CQC also made some “should do” recommendations which will be included in this report on a quarterly basis. The next update on these actions will be received in March 2015. At the last Board meeting a letter was considered from the CCGs providing an update on the system wide issues that were identified at the quality summit. A letter requesting additional detail has been sent to the CCGs in response to this. This report includes an update on the actions agreed by other parties that were recommended at the quality summit. 2. Outpatient update There are four key work streams that the outpatient action plan covers. They are  Environment  Workforce and leadership skills  Communications  Systems and processes The table below details the key actions that are being undertaken for each of the four areas and a RAG status is included:RAG B G A R Ref

Definition Action complete Action being delivered to plan Action delayed or outside of budget but plans in place to bring back on track Action unlikely to be delivered to plan Details

RAG status 3 An Associated University Hospital of Brighton and Sussex Medical School

1.0 1.1 1.2

1.3

1.4

1.5

1.6

1.7

1.8 2.0 2.1

2.2 2.3 2.4

2.5

Environment Minor redecoration and refurbishment in the existing department have been completed The Earlswood centre opened on 4 February for their first diabetes and endocrinology clinics. All clinics (except ante natal) have moved from East Surrey hospital to The Earlswood Centre. Initial feedback from staff and patients has been very favourable. Three Chipstead clinic rooms that were released by move to Earlswood are being refurbished and due to commence with new activity on 2 March 2015. IT solution being explored to support room allocation and monitoring of clinic space. Onsite visit from potential supplier of software system to support room use and allocation has taken place and further meetings to progress a pilot have been planned. A business case is being developed and this will be considered by CHIG and CWG in February. No capital has been allocated to this scheme at the moment and likely cost is estimated at ÂŁ24k. A capital bid pro-forma is being developed. Accommodation for additional ophthalmology clinics being considered at Horsham and a meeting with a property developer has also taken place to discuss the opportunity of having a community ophthalmology centre built on the Earlswood estate. A specification for the service is currently being developed by the clinical team Refurbishment of haematology clinic areas included in capital plan for 2015/16 but work planning to start in February/ March 2015. Plans have been agreed with clinical staff. Chemo outpatient clinics to be accommodated on ESH site following repatriation from Royal Surrey Hospital. Some of these clinics have commenced and the rest will be accommodated when rooms have been identified Report requested from information team to review allocation of patients waiting for outpatient clinics to nearest location to home address and information now available and to be used to inform appointment bookings. Outpatients refurbishment and works project group established and meeting on a weekly basis Systems and processes Trust wide review of demand and capacity underway. Projections around anticipated growth and improvements in new to follow up ratios and DNAs have also been modelled. The top three specialties which equate to more than 20% of all outpatient activity are being focussed on to test forecast demand against clinic templates and job plans. This work will go beyond the 31.3.15 deadline that was originally proposed. Service level review of demand and capacity underway and will be matched with trust wide review. New templates implemented and in place for ad hoc clinics, cancellations and room requests Separate partial booking project team established and plan to be completed. Original aim was to implement January 2015 using Cardiology and Rheumatology as pilot areas but this has been postponed due to lock down of Cerner. Plans being revised to go live in June when Cerner is unlocked. Electronic process for referrals being considered and developed with GPs. Trial being developed with two GP practices.

G B B

G G

B G G

G B A

4 An Associated University Hospital of Brighton and Sussex Medical School

2.6 2.7 2.8 2.9 2.10

2.11

2.12 3.0 3.1

3.2 3.3 3.4 3.5 3.6 4.0 4.1

4.2 4.3 4.4 4.5

KPIs and metrics agreed for monitoring outpatients by steering group Consultant to consultant process reviewed and referrals reduced to minimise financial penalties Monitoring of new to follow up ratios in place on a monthly basis to ensure financial penalties are minimised Weekly monitoring of KPIs commenced and reporting in place at divisional level. Detailed reports for key breaches to be developed Telephone clinics in place for some specialties and tariff being developed to support this more efficient and effective way of working. Rheumatology and gastroenterology are looking at this area in more detail and some software with a years free trial is being explored to support Bleep system to enable patients to leave the department has been explored with other trusts who have system in place. Not considered viable as patients too concerned that they will lose their appointment slot. Self-check kiosk option being considered as an alternative and pilot being explored with potential supplier and a case to support the trial was considered and supported by CHIG in January 2015 Outpatient booking office call answering currently at 98%. Plan in place to improve to 99% Workforce and leadership Interviews for Outpatient Service Manager completed and offer made to strong candidate who commenced at beginning of January 2015. Interim management arrangements in place. Skill mix review of outpatient services continually underway and reviewed each time vacancies arise. Single line management of all outpatient staff considered and agreed not to progress at this point Outpatient steering group and weekly operational groups all in place Back to the floor session by Director of Strategy undertaken in outpatients department Programme to extend skills of nurses being developed and to be worked up in more detail following appointment of new service manager Communications Lead clinician and members of outpatient team have met with a number of GP practices and CCG governance committee to consider views on referrals from GP perspective. This is key to improve working relationships between the Trust and primary care. Lead clinician meeting with clinicians on a 121 basis to gain views and feedback on outpatient services Outpatient services to be included on agenda item for all consultants meeting â&#x20AC;&#x201C; Mid September Outpatient nurse lead to meet with patient experience forum Outpatient focus group for patients planned for 2 December and 157 members interested in outpatients have been invited. Focus groups completed with 14 participants and feedback has informed an action plan which is monitored by monthly outpatient steering group.

B B B G G

G G B B B B B G G G

G B G B

5 An Associated University Hospital of Brighton and Sussex Medical School

Progress against KPIs

6 An Associated University Hospital of Brighton and Sussex Medical School

Update against system wide quality summit actions Clinical Commissioning Groups:  Occupancy rates – Reducing emergency demand – establishing a clear and collaborative programme of action that delivers reduced occupancy in the short and medium term as a key output  Discharge to assess – Full commitment to support the programme going forward  Stop undertaking Continuing Health Care assessments and DSTs in hospital – These should be carried out in the community so that patients get the greatest possible benefits.

7 An Associated University Hospital of Brighton and Sussex Medical School

On all three of these actions an initial response has been provided by the CCGs but additional detail and clarity has been sought 

Move relationships from a transactional basis to a transformational one particularly regarding clinical pathway development through clinically led work



Information sharing – Improve access to and sharing of patient information



Ortho rehabilitation (Including fractured neck of femur) and access to stroke rehabilitation – Developing improved pathways and access to rehabilitation in community settings



Local Transformation Board developing “Hospital Without Walls” -Using existing expertise in the system including winter resilience preparation Collaboration on financial challenges



Evidence of how actions are being achieved and success is being measured has been sought from the CCGs. Healthwatch  Continue to be a critical friend  Encourage Surrey & Sussex to share templates and paperwork (e.g. Continuing Health Care Assessments) Our Chief Nurse and Deputy Chief Nurse have met with Healthwatch members from both West Sussex and Surrey and have agreed to meet them together on a quarterly basis to discuss soft intelligence they have received about the Trust. They have also agreed to consider how representatives from Healthwatch can contribute to relevant work stream within the organisation to increase the patient voice. In addition the Trust has agreed to promote the face of Healthwatch within the organisation to facilitate better knowledge and understanding by patients. Healthwatch were also updated on the recent PLACE visits. General Medical Council  Share lessons from the Surrey & Sussex Healthcare NHS Trust locally and nationally The GMC public relevant reports on their website sharing findings and best practice on a national basis Health Overview & Scrutiny Committee  Continue to bring organisations together and provide challenge  Encourage proactive work with CCGs, GPs & healthcare providers to find solutions for appropriate use of healthcare services  Provide a means of promoting the users and the public to use health services appropriately Provide an opportunity for planning and dialogue with health and social care on demographic changes and access to health services for children and young people

8 An Associated University Hospital of Brighton and Sussex Medical School

The Trust has had recent experience of the West Sussex HASC calling all providers to account for how services had been delivered across the winter months. They have been instrumental in facilitating the agreement of plans which have included a commitment to increasing the social service support being provided on the hospital site Recommendation The Board is asked to consider this report and ensure that it provides assurance around delivery of the CQC improvement plan. Sue Jenkins Director of Strategy February 2015

9 An Associated University Hospital of Brighton and Sussex Medical School

Finance & Workforce Committee

Date: 26 February 2015 Agenda Item: 4.2

REPORT TITLE:

2014/15 QIA Progress & Process Report

EXECUTIVE SPONSOR:

Paul Simpson (Chief Finance Officer)

REPORT AUTHOR:

Peter Burnett – Associate Director of Finance

Action Required: Approval (√)

Discussion (√)

Assurance (√)

Summary of Key Issues This paper outlines the current position on Quality Impact Assessments of the schemes making up the Trust’s 2014/15 CIP programme. The QIA process in the Trust has a clear policy, has a governance structure (including a Quality Assurance Group - QAG) and is owned by the Medical Director and Chief Nurse, who have reported to Board as required. CQC and TDA have advised in the Chief Inspector Review and through the IDM meetings respectively that each is content with our approach, but CQC and our QGAF assessment (by Deloittes) identified that we hadn’t embedded the in-year review element. The in-year review has now been completed as an exercise. It identified the need for more regular feedback to Medical Director and Chief Nurse/QAG to ensure that the full benefit of savings either side of the equation is identified in a timely way to allow intervention, and to review why schemes had not started. A case in point is the neonatal nursing saving attached at Annex A. Other issues are administrative - this review identifies 3 original QIAs not completed (albeit out of 157). Since this was discussed at FWC the Medical Director has asked for the process changes (more real time detail) to be implemented now. This is in progress. In summary: process is adequate, operation of the process requires more attention, but there is no significant assurance or controls gap. Relationship to Trust Strategic Objectives & Assurance Framework: SO2: Effective - Deliver effective and sustainable clinical services within local health economy SO5: Well – led Corporate Impact Assessment:

Legal and regulatory implications

The main regulators, are as follows:  External audit give an opinion on the Trust’s compliance with International Financial Reporting Standards and with NHS accounting conventions – this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trust’s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources.  The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services

Financial implications

Delivery of 2014/15 financial targets

Risk & Performance Management

The committee, and this report, provides assurance about the Trust’s QIA processes.

2014/15 Current Scheme Status The in-year review has now been completed as an exercise. That identified the need for more regular feedback to Medical Director and Chief Nurse to ensure that we weren’t missing anything (a case in point is the neonatal nursing saving attached at Annex A). Other issues are administrative - this review identifies 3 original QIAs not completed (albeit out of 157). Of the 157 original individual schemes identified to deliver the Trust’s 14/15 Savings programme: i)

3 are still awaiting formal sign off by the QIA group

ii)

1 scheme was rejected by the Medical Director and Chief Nurse as the risk was deemed too high

iii)

12 schemes have been provisionally rejected until further evidence is provided that they do not have a detrimental effect on the quality of services provided by the Trust.

iv)

34 were not pursued. These schemes will be revisited as part of 2015/16 business planning process to establish whether these schemes have the potential to provide savings delivery in 2015/16.

107 schemes have been approved by the QIA Group ( of course subject to continuous review)

Not Not Rejected ‐ Approved Awaiting Approved ‐ Pursued Further by Star Final Risk Too Evidence Chamber / Approval High Required QIA Group Surgical Division 1 6 27 Medical Division 6 2 12 3 Women & Children 3 1 16 Clinical Support Services 15 8 11 Cancer 2 Estates & Facilities 1 8 Human Resoures 1 1 Chief Executive 1 Finance 4 Director of Nursing 2 Business Intelligence 3 Corporate Affairs 1 Central Other 2 1 19 1 34 12 107 3

Grand Total

34 23 20 34 2 9 2 1 4 2 3 1 22 157

Development of QIA Review Process It was agreed at the 6 monthly mid-year review by the QIA Group that: a) All CIP scheme owners are to provide positive written assurance to the QIA Group (via a standard template) that their on-going savings schemes are not having an adverse effect on services provided greater than that identified to the Group when the scheme were given initial approval to proceed.

These templates are due to be returned to Management Accounts Section by 12th December 2014 – they will then be collated and forwarded to QIA Group members for review. b) One page monthly reports will be required for all schemes which the QIA Group has particular concerns over - but these concerns are not sufficient to immediately stop the schemes. An example of this is shown in Appendix A. c) The Group has agreed that it should meet formally on a quarterly basis to jointly review all savings schemes. The Group will require Associate Directors of Operations and Divisional Chiefs to be present at these meetings to provide further assurance that their CIP schemes are not having an adverse effect on the quality of services provided.

Appendix A MEETING – Executive Directors Title of paper: Background:

Quality Impact Assessment Monitoring Neonatal Nursing Establishment – Q2 2014 As part of the WACH CIP for 14/15 the Division reduced the Neonatal Nursing overheads funding by £87k. This was based upon a review of the establishment using the DH Toolkit for High Quality Neonatal Services. The Toolkit assesses nursing and cot requirements based upon daily dependency and activity data. As this is a lagging indicator there is a risk that activity will increase beyond planned capacity, therefore actual activity is monitored quarterly by using the Toolkit with the rolling 12 months data. In addition to the Toolkit indicators, actual capacity impact is also monitored using transfers out for non-clinical reasons as the benchmark.

Cot requirements – DH Toolkit Rolling 12 months data Quarterly Performance:

Established

Last Quarter

(baseline)

2014

(Q1 14)

Level 1

Level 2

Level 3 & 4

Nursing workforce requirement (including uplift) – DH Toolkit Established wte (baseline) 37

Q2 2014

Last Quarter

Transfers out for non-clinical reasons - Actuals Cot Capacity

Nursing Capacity

Ex-utero

In-utero

Comments

Levels 1 & 2 cots already over capacity on both occasions

QIA Summary: In-utero transfers out were mainly due to cots already over baseline capacity but also 2 patients at least were below the gestational age for our unit. The safer option to deliver at a unit with NNU capacity for level of care. Staffing establishment gap is manageable at this time and it is appropriate to continue to monitor, full review at year end.

Author:

Bill Kilvington Associate Director Women and Child Health

TRUST BOARD

Date: 26 February 2015 Agenda Item: 4.3

REPORT TITLE:

Annual Plan Progress Update

EXECUTIVE SPONSOR:

Sue Jenkins, Director of Strategy

REPORT AUTHOR (s):

Sue Jenkins, Director of Strategy

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Executive Committee

Action Required: Approval

Discussion

Assurance (√)

Purpose of Report: The purpose of this report is to provide assurance to the Board that the annual operating plan is being delivered Summary of key issues The annual operating plan was approved by the Board in August 2014. This report provides progress against each of the 119 actions for Quarter 3, October to December 2014. Of the 119 actions the status for each quarter is reported as follows Q2 – July to Q3 – October to Status Q1 – April to June 2014 September 2014 December 2014 Red 1 <1% 1 <1% 0 0% Amber 32 28% 24 20% 12 10% Green 64 55% 63 54% 71 60% Blue 19 16% 28 24% 36 30% Progress against delivery of the annual operating plan will be reported quarterly to the Board. Recommendation: The Board are asked to confirm that this report provides assurance that the annual operating plan is being delivered

SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

The annual operating demonstrates delivery of key actions to support the strategic objectives Business cases will be developed for any significant resource developments. The annual plan includes a number of objectives linking to patient experience and engagement Delivery of the annual operating plan is monitored by the executive Committee and reported to the Trust Board The annual plan demonstrates delivery of the organisations strategic objectives

Attachment: Annual operating plan Q3 update

2 An Associated University Hospital of Brighton and Sussex Medical School

Annual plan progress report - Q3 (October to December 2014) Key for RAG status Workstream off track and unlikely to R deliver as described

Workstream offtrack but plans in place to recover

Workstream on track and to plan

Workstream complete

Q2 Update

Q3 Update

SO1 - Safe - Deliver safe services and be in the top 20% against peers

Action

Timescale for updates

Lead Director

Lead Manager/clinician

1.1 Strategic objectives delivery plan

Review CQC live link to mortality rates on a monthly basis

Quarterly

Des Holden

Ben Emly

1.2 Strategic objectives delivery plan

Gain CQC inspection rating of good or outstanding

Jul-14

Fiona Allsop

Ref

Source

RAG status Reviewed monthly via clinical effectiveness committee

1.3 Strategic objectives delivery plan

Quarterly audit of clinical staff appraisals to demonstrate that patient safety goals are included

Quarterly

Des Holden

Adam Stacey-Clear

Reviewed monthly via clinical effectiveness committee B

"Good" rating achieved from CQC for all domains

Commenced introduction of safety goals as part of appraisal process. Audit to check compliance planned for December 2014

Audit completed and demonstrated that patient safety goals are in place Jan-Mar 13 - 4 SSIs Apr-Jun 13 - 2 SSIs July-Sep 13 - 3 SSIs Oct-Dec 13 - 2 SSIs Jan-Mar 14 - 0 SSIs Apr-Jun 14 - 2 SSIs

1.4 Clinical strategy

Maintain the low incidence of surgical site infections

Quarterly

Des Holden

Barbara Bray

Jan-Mar 13 - 4 SSIs Apr-Jun 13 - 2 SSIs July-Sep 13 - 3 SSIs Oct-Dec 13 - 2 SSIs Jan-Mar 14 - 0 SSIs Apr-Jun 14 - 2 SSIs RAG rated AMBER as elective orthopaedic beds are not ring fenced as per best practice.

Divisional plans Clinical strategy 1.5 Divisional plans

Meet all access targets including 2 weeks referral, 31 days and 62 days

Quarterly

Paul Bostock

Ben Emly

TWR, 31 and 62 day standard being met Cancer standards being met although a challenge in terms of consistency with screening standard

TWR, 31 and 62 day standards being met. RTT TBC ED Q3 not achieved

Clinical strategy 1.6 Divisional plans

Complete and in place

Maintain consultant obstetrician cover at 98 hours per week

Quarterly

Des Holden

Debbie Pullen

Clinical strategy 1.7 Divisional plans

Maintain compliance with national midwifery ratios

Quarterly

Fiona Allsop

Michelle Cudjoe

Clinical strategy 1.8 Divisional plans

Achieve compliance with new CNST standards

Quarterly

Fiona Allsop

Michelle Cudjoe

1.9

Quality Account

Improve data collection

Quality strategy

Commence monthly falls clinics and falls ward rounds

Avoidable falls/ falls resulting in harm

Quarterly

Fiona Allsop

Sally Brittain

Reduce falls by 25%

1.10

Quality Account

Quality Account Quality strategy

B Trust has a rolling programme of investment to achieve the national ratio over 2-3 years

Trust has a rolling programme of investment to achieve the national ratio over 2 - 3 years

CNST standards no longer valid or used to measure quality of maternity services. Focus has now shifted to CQC inspections. Consider complete

Complete

Actioned and in place On going- Consultant Nurse for Falls commenced Dec 2014

Actioned and in place Consultant Nurse now in place with a work plan to support a reduction.

B A

No 3 or 4 since Jan 2013 , pressure damage rate remains low and Unchanged position PD remains in single figures with no major unchanged. pressure damage. Sally Brittain

Safety thermometer

Develop and introduce maternity safety thermometer

Quarterly

Fiona Allsop

Michelle Cudjoe

National tool still being piloted . Seeking to join national pilot formally. Contact has been approached to progress

Continuing to develop whole systems pathway across Surrey. Aiming to extend to cover Sussex teams in the New Year. Focus groups being established to support development of dementia strategy. Butterfly scheme in place and ongoing.

Steve Adams

Continuing to work with community provider colleagues to help establish a view of dementia care which reflects the importance of community based care, but acknowledges the important role hospital can play at times. Dementia strategy being developed. Butterfly scheme has been launched which raises awareness of dementia helps improve interface patients Dedicatedand questions now forming part for of the "Yourbetween care matters"

Develop community facing approach to dementia care Seek feedback from carers of dementia patients

Quarterly

Fiona Allsop

Quality Account Healthcare acquired infection

Meet the DH central infection control targets of <29 Cdiff cases and no preventable MRSA blood stream infections

survey Feedback from â&#x20AC;&#x153;your care mattersâ&#x20AC;? will form a standing agenda item for the Dementia Strategy Group being established to demonstrate how learning is actioned

Demonstrate how feedback from carers has been used to improve services

Dedicated questions now forming part of YCM In addition to YCM considering development of a dementia friendly FFT. Dementia patients and carers to be invited to focus grpoups to support development of dementia strategy

Quarterly

Fiona Allsop

Ashley Flores

MRSA screening in progress and reported on Performance scorecard.

Quality Account

Continue risk assessment on > 95% of patients on admission

Compliant with 95% across the Trust and work in place to look at compliance by specialty. Targetting trauma and cardiology.

Quarterly MDT review of all VTE cases

Quality strategy

Venous thromboembolism (VTE)

To date, the trust has had 0 MRSA blood stream infections and 11 To date, the trust has had 0 MRSA blood stream infections and 17 cases of Clostridium difficile. cases of Clostridium difficile.

Continue to screen patients for MRSA and administer MRSA suppression treatment in a timely way

Quality strategy

Fiona Allsop

Dementia

1.14

Quarterly

Quality strategy

1.13

Reduce hospital acquired minor damage by 25% and have no hospital acquired major pressure damage

Quality Account

1.12

Skin care

Quality strategy 1.11

Des Holden

Clinical Chiefs

MDT review of all cases in place. MDT review of all VTE cases in place Aiming for 100% on discharge assessment and RCA on confirmed VTEs

Quality Account 1.15

Quality strategy

World Health Organisation (WHO) safer surgery checklist

Continue to audit quality of safer surgery processes

Fractured neck of femur (hip)

Maintain and further improve timely admission and operative intervention Quarterly Improve length of stay for #NOF

Quality Account Quality strategy 1.16 Clinical Strategy

Des Holden

Barbara Bray

Des Holden

Barbara Bray

Paul Bostock

Paula Tooms

Des Holden

Ben Mearns

Improve follow up data collection and reporting

Divisional Plans

Reinforce ring fencing to admit stroke patients within four hours to acute stroke unit

Quality Account Quality strategy 1.17

Quarterly

Patients admitted with stroke

Further improve scanning time

Quarterly

Review stroke coding and mortalities for 2013/14

Des Holden

Ben Mearns

Quality Account

Quality strategy

Increase number of audits that impact on patient safety

Incident reporting

Quarterly

Site team continue to document all stroke call patients for admission to ring fenced beds. Process in place to escalate when only 1 ring fenced bed avaialble.

Site team continue to document all stroke call patients for admission to ring fenced beds. Process in place to escalate when only 1 ring fenced bed available - Consider complete

Enabled nurse practitioners in ED to order scans to improve times Nurse practitioners in ED ordering scans Coding review complete. Stroke HSMR< 100 for the last 2 months Coding review complete. Stroke HSMR< 100 for the last 4 months

G B

Fiona Allsop

Evidence from the latest reports to the Clinical Effectiveness Committee identified which audits had been started as a result of incidents/risks as a proportion of their audit programme. • The Duty of Candour regulations are now a statutory requirement. The Being Open Policy is being updated to include the new requirements. Datixweb has been updated to ensure that compliance can be recorded and monitored. • Work is taking place within the Divisions to ensure that the requirements of Duty of Candour are understood by care givers and appropriately recorded for audit purposes. • The use of user KPI dashboards on Datixweb will be developed in the last quarter of 2014/15 to provide real time analysis of incidents.

Sue Jenkins

• The first quarterly SI report has been presented at the Public Trust Board. • Each Division has a Risk & Patient Safety Manager who supports their Division in managing incidents and serious incidents. Each of the Divisional Risk Managers provides the Division with patient safety incident data at the Governance Meetings. • The Divisional leads attend the Patient Safety Sub-Committee at which learning from incidents is shared and discussed. • Patients/relatives are informed if a serious incident investigation is being undertaken and are sent the completed reports and asked if they want to meet the relevant person from the Trust to discuss Quality improvement plan developed. To be reviewed and updated by ECQRR 6 monthly Being monitored via Divisional Quality and Risk Boards Outpatients plan in place and being delivered and monitored by steering group. Weekly meetings in place with operational teams. Weekly reporting of key metrics in place. Some time scales have slipped against oiginal plan. Plan monitored via weekly updates to executive committee and monthly board updates

Outpatients plans continueing and being monitored by steering group. Weekly meetings in place with operational teams. New Outpatient Service Manager in place as of 19th Januray. Weekly reporting of key metrics in place. Business cases for various improvements being worked up in order to improve patient experience. Good communication channels being developed with GPs and CCGs. Plan monitored via weekly updates to executive committee and monthly board updates Environment issues carried forward to capital plan for 2015/16 Reduction in ad hoc clinics included as part of outpatient metrics Consider complete

Katharine Horner

Ensure delivery of all actions on deep dive quality improvement plan

Compliance with ring fenced beds compromised by winter pressures. Peaks in activity sometimes compromise pathway. LOS still above average National #NOF data base now available and Trust is average in the region for all areas

Make patient safety data more transparent for staff and patients

1.19 Deep Dive Quality Improvement Plan

Compliance with ring fenced beds good with average activity. Peaks in activity sometimes compromise pathway. LOS still above average National #NOF data base now available and Trust is average in the region for all areas

• A “Shared Learning in Practice” newsletter is planned for publication each month which will highlight key learning from Serious Incidents across the Trust. • A cross Divisional Serious Incident Review Group has been established to provide support and leadership in the analysis of incidents and the production of Root Cause Analysis reports. The group provides an opportunity for experiences and learning to be shared by team leaders.

Jonathan Parr

1.18

• The Divisional Governance Meetings are taking place on a regular basis within the Divisions. A Divisional summary report is presented to the Patient Safety Sub-committee which covers incidents reported, outstanding SI investigations, SI actions, lessons learned. • A “Shared Learning in Practice” newsletter is planned for publication each month which will highlight key learning from Serious Incidents across the Trust. • Work will start with Communications on the possibility of having a Divisions set their own divisional audit plan and these include any audits that have been identified as required in an action plan resulting from an incident investigation.

Katharine Horner Improve use of safety information at divisional meetings

Included in theatres safety thermometer for continuous monitoring Included in theatres safety thermometer for continuous monitoring and annual in depth audit in place. WHO checklist usage is 100% and annual in depth audit in place. WHO checklist useage is 100% compliant. compliant

ADOs

Quality improvement plan developed. To be reviewed and updated by ECQRR 6 monthly Being monitored via Divisional Quality and Risk Boards and as part of Deep Dive process for 2015 - Consider complete

1.20 CQC improvement plan

Deliver outpatients improvement plan

Quarterly

Sue Jenkins

Garry East Sian Griffith

1.21 CQC improvement plan

Deliver medical records improvement plan

Quarterly

Ian Mackenzie

Phil Stone

Environment issues carried forward to capital plan for 2015/16 Reduction in ad hoc clinics included as part of outpatient metrics Consider complete Project Board meeting fortnightly. Implementation group established and reporting to project Board on implementation of the project plan by 31.03.15

Project Board meeting fortnightly. Implementation group established and reporting to project Board on implementation of the project plan by 31.03.15 Roll out plan currently being implemented

Improvements to PTS / EDS planned for early 2015. This will enable the discharge prescription to be written ahead of the rest of the discharge letter

1.22 CQC improvement plan

1.23 Quality Account NEW

Deliver Dictate IT improvement plan

Quarterly

Jim Davey

Angela Stevenson

Improve communications and information around medication on discharge

Quarterly

Paul Bostock

David Heller

Timescale

Lead Director

Lead Manager/clinician

SO2 - Effective: Deliver effective and sustainable clinical services within the local health economy Ref 2.1

Source IBP service development

Action Develop second cardiac angiography suite

Quarterly

Paul Bostock

Decrease non elective care – develop additional hospital at home services, community beds and geriatricians in the community to support the QIPP plans delivered through the LTB

Quarterly

Paul Bostock

Estate Strategy IBP service development 2.2 Strategic objectives delivery plan

Angela Stevenson

Q2 Update

RAG status

Build commenced. Pause planned from December to March to accommodate winter pressures. Go live deferred due to planned pause Non elective activity increasing vs Q2 13/14 and above commissioned plan. Hospital at home pathways in development and increasing to 30 beds over the winter via phased implementation QIPP plans unlikely to be delivered -

IBP service development 2.2a Strategic objectives delivery plan

Manage non elective care - implement additional hospital at home services, community beds, geriatricians in the community, additional wards for winter, discharge to assess initiative and 7 day a week palliative care services

Quarterly

Paul Bostock

1st stage of build completed on time. Pause now in place to supprt winter pressures. Completion due Summer 2015

Replaced by 2.2a as agreed by Board in November 2014

Sash at home beds extended over the winter Additional wards of 32 beds open and in place for the winter 3rd ward being built to increase surgical capacity in the Spring Discharge to assess initiative in place and criteria being extended 7 day a week palliative care services in place January 15

2.3 IBP service development

2.4 Strategic objectives delivery plan

2.5 Strategic objectives delivery plan

2.6 Strategic objectives delivery plan

Joint pathology venture

Demonstrate participation in wider health system transformation forums to influence development of new models of care

Develop decant and escalation ward

Develop plans to support re-procurement of EPR and EPMA

31.12.14

Quarterly

31.12.14

Quarterly

Paul Simpson

Sue Jenkins

Paul Bostock

Ian Mackenzie

Bruce Stewart

Angela Stevenson

Anna Wickenden

Clinical strategy 2.8

2.9

Divisional plans Clinical strategy Divisional plans

Continued participation in Strategic Resilience Groups Stroke network and clinical pathway development Chief Officers meeting

Ongoing discussions re BCF implications with both Surrey and West Sussex communities

Ongoing discussions re BCF but no firm plans have been shared from CCGs to date

Build progressing. Due for completion December 2014. On plan

Opened on 29 December 2014 and complete

EPR - procurement exercise undertaken; Cerner awarded preferred supplier status; Full Business Case approved by Finance and Workforce committee and TDA; awaiting subsequent contract sign-off. Initial transition to the Cerner data centre is planned for 31st May 2014, subject to Exit programme constraints.

EPR - Contract has been signed. Transition is underway with golive currently scheduled for the 20th June 2015. Change freeze will come into effect on the 25th of January. - Managed by Glyn Bigmore (glyn@nautilus-consulting.co.uk)

EPMA - the Cerner e-prescribing functionality, discharge summary and ED single encounter solutions are planned for deployment 30th November 2014. The PIEDW reporting solution and business continuity solutions are technically live.

EPMA - ED Single encounter live since 30th Nov. Capel Annex pilot live since the 8th Dec. Pilot evaluation starting 26th Jan with David Heller to provide options paper for next steps to ops group end of Feb. Ongoing issues with Discharge Summary being addressed with suppliers. 13 Care of the Elderly consultants now appointed. Approximately 50% of their time is committed to delivering services in an out of hospital environment supporting primary care and community services

Involved in Surrey and Stroke networks to redesign services across whole healthcare system. Led work with CCGs to improve pre hospitals and post discharge care

Quarterly

Des Holden

Virach Phongsathorn

Redesign the stroke pathway to create a seamless in and out of hospital patient centred pathway across all providers

Quarterly

Des Holden

Ben Mearns

Involved in Surrey and Stroke networks to redesign services across whole healthcare system. Led work with CCGs to improve pre hospitals and post discharge care

Ben Mearns

Discharge to assess implemented September 2014 and evaluation Focussed 3 week assessment of all discharges by 20/20 of pilot underway undertaken in November which has informed future qork streams Discharge to assess continuing and criteria being extended

Redesign the pathways in elderly medicine to create seamless patient care across all providers including early supported discharge

Quarterly

Des Holden

Continued participation in maternity, children's, neonatal, cancer, critical care, stroke, and vascular networks Active participation in all clinical networks

Quarterly

Des Holden

Develop community based diabetic services providing locally accessible services

Quarterly

Sue Jenkins

Vikkie Bailey

Continued participation in maternity, children's, neonatal, cancer, critical care, stroke, and vascular networks G

Clinical chiefs

Clinical strategy 2.11 Divisional plans

Continued participation in Strategic Resilience Group Stroke network clinical pathway development Chief officers meeting (which has replaced LTB)

13 Care of the Elderly consultants now appointed. Approximately 50% of their time is committed to delivering services in an out of hospital environment supporting primary care and community services

Clinical strategy Divisional plans 2.10

FBC approved by both Trust Boards in September to develop pathology services as a single managed service via a contractual joint venture. Implementation phase now in progress heading for go live in April 2015

Enhance community geriatrics and share secondary care expertise into the community

Clinical strategy 2.7 Divisional plans

Discussions still underway with NHS property services, FCH and solicitors with regard to vacation of premises and date of lease occupation

Property now vacated by FCH and plans to take occupation on 5 January and commence clinics on 4 February in place and being delivered

Open and complete

Estate Strategy Clinical strategy

Develop and implement respiratory unit in partnership with BOC and Quarterly Guys & St Thomasâ&#x20AC;&#x2122;

Ian Mackenzie

Redesign service to create HDU respiratory beds

Quarterly

Des Holden

Divisional plans

Provide integrated critical care service with intensivist medical cover in the high dependency unit

Quarterly

Des Holden

Barbara Bray

Clinical strategy Divisional plans

Develop a day surgery strategy to increase % of all surgical procedures to 80% as day cases

Quarterly

Paul Bostock

Natasha Hare

Develop 23 hour day surgery at Crawley hospital

Quarterly

Paul Bostock

Natasha Hare

Develop and implement dental simulation suite

Quarterly

Paul Bostock

2.12 Divisional plans

Estate strategy Clinical strategy 2.13

2.14 2.15 2.16 2.17 2.18

Divisional plans Clinical strategy

Clinical strategy Divisional plans Clinical strategy Divisional plans Clinical strategy Divisional plans

Clinical strategy 2.19 Divisional plans

2.20

Clinical strategy 2.21 Divisional plans

Medical bed strategy proposed and business case being developed

The respiratory high dependency unit, Tilgate Annex will be on stream in early spring 2015. Plan is now in place to develop NIV bay/high dependency respiratory beds with in the annex.

Commenced 1 August 2014

Q2 average at 87%

Q3 average 88%

Commenced September with phase 1. Phase 2 due January 2015 Commenced September with phase 1. Phase 2 due January 2015

Lead clinicians Deliver and implement new radiotherapy services on site at ESH site Quarterly

Ian Mackenzie

Redesign of service to ensure that the birthing unit provides intrapartum and postnatal care for 20% of women booked for maternity services at East Surrey hospital

Des Holden

Debbie Pullen Quarterly

Clinical strategy Divisional plans

Virach Phongsathorn

Garry East Des Holden

Redesign of service to support the installation of a digital mammography machine on the ESH site

Paul Bostock

Bruce Stewart Quarterly

Complete and open summer 2014

Currently being achieved. 22% of all births last month

Currently being achieved. 20% of all births last month

Garry East

5 year strategy produced and being overseen by working group in radiology. Chaired by newly appointed radiology services manager. Workforce planning in progress to finalise establishment required for 2015/16 planned activity

Business case developed. Funding sources being explored including TDA, capital and charitable funds

Currently awaiting confirmation to proced with Business case. Funding sources being explored including TDA, capital and charitable funds

SOC approved by TDA in November. Project continues to be overseen by PMO. Decision pending

Currently awaiting confirmation to proced with Business case. There is an affordability gap that needs to be addessed before this can be taken to the next stage

Estate Strategy Clinical strategy 2.22

Bruce Stewart Implement a managed equipment service which is supported by a rolling equipment replacement schedule

Quarterly

Des Holden

B G G B B

Michelle Cudjoe Bruce Stewart

To consider recommendations from the strategic review of radiology services undertaken in autumn 2013 and agree and implement action Quarterly plan

Complete and open summer 2014

Divisional plans 2.22

Implement a managed equipment service which is supported by a rolling equipment replacement schedule

Quality Account 2.23

Mortality Quality strategy Quality Account

2.24

Readmission to hospital

Quality Account Quality strategy

Quarterly

Enhancing Quality (EQ)

Maintain 2013/14 position

Quarterly

Enhanced recovery (ER)

Further increase use of enhanced recovery Maintain high levels of data completeness to demonstrate improvements

Quarterly

Increase statement compliance

Quarterly

Quality Account 2.26

Quarterly

Undertake review of one month’s clinical readmission data and implement any lessons learned

Quality strategy

2.25

Roll out enhanced review of all patient deaths Maintain “better than expected” rating for mortality by Dr Foster Improve on changes made on 13/14

Garry East

Quality strategy

Des Holden

Jonathan Parr

Jim Davey

Des Holden

Jonathan Parr

Quality Account 2.27

Quality strategy

(NICE) technology appraisals

2.28

Reducing need for admission Quality strategy

2.29 7 day working SDIP

Des Holden

Maintain core community and hospital at home beds all year

Quality Account

Review pathways to develop alternatives to admission

Implement 7 day working for all relevant specialties

Jonathan Parr Paula Tooms

Quarterly

SOC approved by TDA in November. Project continues to be overseen by PMO. Decision pending

Paul Bostock Jim Davey

Quarterly

Sue Jenkins

Timescale

Lead Director

Initial feedback in October meeting and agreed template for trustwide use Continues to improve

Currently awaiting confirmation to proced with Business case. There is an affordability gap that needs to be addessed before this can be taken to the next stage

Improvement demonstrated in annual plan

Template now being rolled out and update on progress will be reported and next Mortality Group The annual re-basing of the HSMR still saw the Trust perform better than expected compared with the national average. Improvement demonstrated in annual plan

Readmission audit completed October 2014 resulting in a readmission rate of 7%which is one of the lowest in the country.

Data completeness targets being met and first six months show position being maintained.

Data completeness targets continue to be met.

G G B

Scores presently not showing sufficient increase in use of ERP as Scores presently not showing sufficient increase in use of ERP as defined by CQUIN defined by CQUIN Data completeness targets being met although extensions have Data completeness targets now being met been required to deadlines due to staff absence.

Chief Pharmacist has been asked to produce list of Tas to be audited to demonstrate compliance.

Chief Pharmacist identified six TAs to be audited to demonstrate compliance. These are now with the Divisions to be audited.

Plans in place to increase hospital at home beds to 30 at the end of Q3 Discharge to assess pilot implemented and 5 patients now discharged. Review of ambulatory care pathways underway with CCGs

At end of Q3 23 beds in place. Still aiming to increase to 30 by end of Q4 Discharge to assess progressing and 16 patients discharged to end of December 2014

Working group not meeting regularly but work progressing with Palliative Care team extending to 7 days

NHS leadership academy have offered 7 day working support and this work will commence in Q4

SO3 - Caring - Ensure patients feel cared for and cared about Lead Manager/clinician

Q2 update

Des Holden

Clinical chiefs

Audit plans include issues raised by patients via a number of sources including complaints and incidents

Demonstrate delivery of “Provide safe and effective care in all that we do” objective from nursing and midwifery strategy at patient Quarterly experience committee

Fiona Allsop

Sally Brittain DCNs

3.3 Strategic objectives delivery plan

Develop and roll out customer care training for all relevant staff

Yvonne Parker

Clinical strategy 3.4 Divisional plans

Work with Olive Tree, Friends of east Surrey and Macmillan Cancer Support to develop and implement a Cancer Information and Support Quarterly Centre at East Surrey Hospital

Ref

Source

3.1 Strategic objectives delivery plan

3.2

Strategic objectives delivery plan Nursing & Midwifery strategy

Action

Demonstrate that audit plans include issues raised by YCM, FFT and Quarterly inpatient survey

Quality strategy

3.6

Right bed, right time

Quality Account

Bill Kilvington Paul Bostock

Jane Penny

Eliminate clinically inappropriate mixed sex accommodation

Quality Account

3.5

Quarterly

Nutrition

Quality strategy

Increase community beds and investment in 7 day working

Quarterly

Ring fence beds for stroke and fractured NOFs Develop escalation process and bed plan Continue to focus on implementing protected mealtimes and audit Quarterly compliance Introduce two week menu

Quality Account

Implementation of system wide pressure damage board to support Paper to go to NMPC February 2015 detailing delivery. improvments in pressure damage prevention.Senior nurse walk rounds weekly.Coordination of sit and see observations of care as a supportive way to monitor care , kindness and compassion. Further customer care training package agreed for medical The programme has been agreed and handed over to the Training secretaries and other relevent admin staff Team to administer. A specific programme has been developed for medical secretaries. One of the HRBPs is liaising with the training provider. Planning permission has been granted and a tendering process agreed so that the FBC can be subitted to the FWC in January

Tendering process on going. Oncology manager post to be advertised to start volunteer recruitmentto support opening

No breaches in Q2

No breaches in Q3

7 day project plan in place but team not meeting at the moment. NHS leadership academy to support Trust with 7 day work stream Supported discharge for end of life care patients being extended to 7 day palliative care team now in place 7 days Community beds included in bed plan which has been presented to and approved by Board Extended escalation processes now in place and whole policy to Beds identified and policies agreed to support implementation be reviewed to incorporate Complete and in place Complete and in place

Paul Bostock

Fiona Allsop

Sally Brittain

Ian Mackenzie

Carol Dixon

Fiona Allsop

Review and update End of Life Strategy

Quality strategy

Protected mealtimes in place on all wards and in addition Audit planned for December 2014

Audit complete and fully compliant

Two week menu Implemented June 2014

Been to N& M Board and ratified for next 3 years

End of life care

Promote use of and audit compliance with End of Life Care Plan

Introduce a palliative care weekend service by recruiting two additional CNS’

G B B B B

Been to N&M Board and palliative care team reveiewing plan

3.7

RAG status Audit plans include issues raised by patients via a number of sources including complaints and incidents

Quarterly

Jane Penny

Paul Bostock

Business case for supported discharge scheme with Marie Curie approved. Service which will cover 7 days a week will commence in Q4

Pall Care team currently auditing the EOL care Plan to be discussed in the EOL care steering group 15.1.15. Aim to develop themes to affect changes. EOL care plan presented in Trust STAT training. The PCT have commenmced 6 day working to include saturdays and bank holidays. I nurse recruited on training programme.

Business case for supported discharge scheme with Marie Curie approved. Service which will cover 7 days a week will commence in Q4. I post recruited into and still to appoint into the other DLP post and HCAs

3.8 Quality Account NEW

3.9 Quality Account NEW

Amber care bundle

Consider use and implementation of amber care bundle and roll out if Quarterly relevant

Fiona Allsop

Jane Penny

COPD bundle

Implement COPD bundle to offer personalised care plan, consider Quarterly personal budgets, improved access to information for carers

Des Holden

Ed Cetti

SASH cannot take part in the amber care bundle. Guys and st thomas have stopped the roll out while tey evualate the programme. We have registered our interest and await the results of their evaluation COPD bundle is now established and 90% patients now receiving it. Trigger for it has now been added to PTS. Re-admission rates show significant improvement.

SO4 - Responsive to people's needs - become a secondary care provider and employer of choice for the catchment populations of Surrey and Sussex Ref

Source

4.1 IBP service development

Action

Timescale

Bowel screening service development

Quarterly

Lead Director Paul Bostock

Lead manager/clinician

Q2 update

Natasha Hare

Commenced September and up and running. Complete

On-going strategic development. Including discussion with Macmillan for capital support

Capacity remains an on-going issue at ESH chemotherapy day unit. Newly structured oncology steering group meetings with RSCH to continue to support additional regimes being relocated.

Gary Mackenzie Bill Kilvington

4.2 IBP service development

Chemotherapy service development

Quarterly

Paul Bostock

Strategic objectives delivery plan

Jane Penny Katrina Swanston

Establish CoG and demonstrate meaningful engagement which shapes our services

4.3

Quarterly

Gillian FrancisMusanu

Membership strategy

Colin Pink

Clinical strategy

Bill Kilvington

Divisional plans

Barbara Bray

4.4

Refurbish and open theatres

Quarterly

Paul Bostock

Estate Strategy

Quality Account

Encourage more frontline staff to respond directly to comments on Patient Opinion

Quality strategy

Roll out YCM to all wards and departments

4.5

Patient feedback

Good progress made in this quarter and theatres 7 & 8 on Theatres 7 & 8, plus the maternity recovery were completed and schedule for opening in December. Completion of all clinical areas opened, although delayed by a week due to a problem with the on track for mid April 15, with full completion in June 15. ventilation controls. The temporary recovery is operational while the main recovery is undergoing a full re-build which is due or completion in June 2015

Sally Brittain

Complete

Quarterly

Fiona Allsop

Complete

Focus groups with patients have been held which has identified issues that will be addressed as part of patient leaflet redesign

Considering a withdrawal from the AQP NOUS for North West Surrey due to financial and staffing issues (the low return on investment). Participating in the service spec review for the Non-invasive ventilation (NIV) service led by Sussex Collaborative Team and exploring the option of joint partnership for bidding and delivering the service with another provider. Options paper will go to Execs when the AQP is published by CCGs. Trust assessed the option of joint partnership with the current service provider for bidding for the AQP Community Dermatology Service (CDS) but decided not to proceed on the basis of under valuation of activity and financial envelope.

Trust withdrew from the AQP NOUS process for North West Surrey, due to insufficient contribution to overheads and a potentially high level of risk. The Contract for the NOUS service (AQP for East Surrey CCG) was signed in Dec-14 and service officially commenced on 1st Jan15, which was communicated to local GPs via GP Newsletter. The MSK prime provider has been selected by CCGs as Sussex MSK Partnership (a partnership between Brighton Integrated Care Services, Sussex Community NHS Trust, Sussex Partnership NHS Foundation Trust and the Horder Centre). The Trust has secured a Contract for 2014/15 in line with the existing CCG Contract and with further beneficial terms. Contract negotiations are currently underway and the impact on Trust's services and details of the contract still remain unclear, patients currently receiving treatment will continue to receive care from the existing teams and services. The Trust is awaiting the publication of tenders for Non-Invasive Ventilation (NIV) Service (led by Sussex Collaborative Team) and Tier 4 Weight Management Service (Bariatric Surgery) by NHS England, once the locally commissioned tier 3 service is shown to be functioning well. Training on Hospital Marketing Manager module of the Dr Foster online system was arranged for Divisional Service managers and held on 24 Nov-14.

Cathy White Sally Brittain Barbara Bray

Quarterly

Paul Simpson

Larisa Wallis

Updated market share analysis for SASH for 2013-14 and the last six years including GP referral trends. Ongoing work on raising awareness among GPs of new services provided by SASH.

4.7 Market Development strategy

Improve both admission and discharge patient literature

To maintain market share through excellent service provision and securing AQP contracts where CCGs have given notice on the service that was previously part of the acute contract

Provisional election timescale agreed with ERS and in place. Provisional election timescale agreed with ERS and in place. Awaiting "go-live" following B2B. Draft consitution - approved legal Awaiting go live of election following Board to Board. opinion confirmed. Staff Governor awareness sessions held. Draft constitution approved and legal opinion confirmed. Staff governer awareness sessions complete

Complete

Communicate changes we make to staff and patients

4.6 Market Development strategy

RAG status

To expand market share for elective activity targeted market for those GP practices within our catchment that have traditionally referred Quarterly patients to other providers

Paul Simpson

Larisa Wallis

Trust Market Development Group has been set up and met twice since November 2014. ToR, membership and priorities are to be agreed in March. 2015/16 Business Planning workshop is arranged with Divisions for 5th Feb-15 to identify any market gaps, business opportunities and threats for SASH in 2015/16. The Trust is holding a series of Hot Topic events for GPs and other referrers & stakeholders to showcase Trust services (Care of Elderly; Emergency Care). Since the opening of St Luke's Unit (in conjunction with RSCH / St Luke's Cancer Centre in Guildford) SASH has repatriated chemotherapy activity from local GPs previously sent to RSCH.

B B

Plan to open new Angiography lab in July 2015. Working with MSK prime provider for Sussex on pathways review. St Luke's Radiotherapy Unit is up and running. Bowel Screening - commenced in-house Macmillan Cancer Centre - planning approval received and business case approved

4.8 Market Development strategy

To expand market share for elective activity by working with CCGs and other providers to repatriate elective activity from distant tertiary providers where this is clinically appropriate

4.9 Market Development strategy

To explore opportunities for further joint ventures/partnership arrangements to continue to develop the East Surrey Hospital campus so that local patients can receive an increasing range of specialist services at ESH whether provided by SASH or a partner organisation

4.10 Market Development strategy

To move to new markets, such as private practice, where this is clinically and financially viable and supports the long term strategic intentions of the Trust

4.11 Workforce and OD strategy

Launch the Leadership Framework and an effective assurance process for the organisation to assess how each line manager is Quarterly performing against the key people performance requirements

Yvonne Parker

Sally Knight

4.12 Workforce and OD strategy

Develop integrated workforce plans (demand and supply) at divisional/ business unit level - identifying workforce changes Quarterly required for 24/7 working in appropriate areas

Yvonne Parker

Janet Miller

Quarterly

Paul Simpson

Larisa Wallis

4.13 Workforce and OD strategy

Remeo / BOC contract for clinical services has been signed. Macmillan Cancer Centre - planning approval received and business case approved Ongoing work on new services commissioned and provided under provider to provider agreements and contracts.

Three new wards and Cardiology Angiography Suite (due to open in July 2015) will enable the Trust to increase its market share for elective activity in second half of 2015/16. Engaged in market testing exercise with Collaborative Hub on NIV (Respiratory) service. Ongoing process of renewal, contract negotiation and agreement of provider to provider agreements (SLAs).

Review of the Trust private patients policy and processes. Working up a new price list for private patient procedures. Signed the CT network agreement with BUPA for provision of routine outpatient CT scans for private patients.

Private Patients Project Group is being established within the Trust with the aim to grow private patient activity as well as to draw up the Trust's strategy and review of policy for private patients.

LF to be incorporated into clinical leadership development. LF competencies in management training matched to LF. GE Sash Plus work consistent with LF competencies.

Preparation for revised Achievement Review Process (Appraisal) in April 2015.

on going, planning still at high level

On going, planning still at high level

 realise the benefits of technological business processes across the Trust eg attendance and rostering software, digital dictation, Quarterly

A change of ownership required, no longer under HR

Focus on increasing workforce productivity

The Trust has been improving and introducing new services which is evidenced by increasing referrals for elective activity and broadening of services offered by SASH (e.g. introduction of services in cancer - chemo and radiotherapy, McMillan Centre, expansion of cardiology services to provide 24/7 angiography and the joint venture in pathology services with BSUH). Although there has been a growth in overall volume of elective activity for SaSH, there has been no growth in SASH market share, meaning other providers activity is growing faster. This is due to the competitive healthcare market as well as the pressure from increasing demand in emergency care activity (our waiting lists have grown). Trust investment in new modular wards and 24/7 services (e.g. Cardiology) will lead to the gradual increase in volume and market share for elective care.

Paul Bostock

Completed GE benchmarking report detailing productivity Erostering updgrade complete EPMA pilot in place Regular reports to FWC on progress against productivity

 harness productivity gains identified in service developments advances in medical/surgical innovations eg telemedicine, Output from values champions to be incorporated into revised Values champions network to be launched Dec 14. The processes induction slides to embed values for new staff will follow

4.14 Workforce and OD strategy

Refocus of induction to support OD intervention around behaviours Quarterly and values.

4.15 Workforce and OD strategy

Have in place a range of interventions to reduce the top reasons for absence such as workplace stress musculoskeletal disorders (MSD), Quarterly flu.

Yvonne Parker

Janet Miller

4.16 Workforce and OD strategy

Ensure that staff have access to a range of services to support Quarterly healthy lifestyles, diet and health screening.

Yvonne Parker

Sally Knight

4.17 Workforce and OD strategy

Create the SaSH identity and brand so that we are recognised as the Quarterly ‘Employer of Choice’

Yvonne Parker

Sally Spencer

Deliver all QGAF action plan

31.08.14

Des Holden/ Fiona Allsop

Colin Pink

External assessment complete and score of 3.5 confirmed. Gaps External assessment complete and score of 3.5 achieved. being addressed via weekly meeting reviewing action plan in place Gaps being addressed via a weekly meeting reviewing the action to reduce score further plan in order to reduce score further. On track for delivery of all QGAF actions by the end of Q3

Timescale

Lead Director

Lead manager/ clinician

Q2 update

Yvonne Parker

Sally Knight

monitoring through workforce metrics and reported to workforce committee

Wellbeing day planned for 4th March 15

4.18 QGAF

Promotion of CIC helpline (Trusts outsourced EAP provider) at all OH referrals for stress and at calls to Firstcare for this reason for absence. Promotion of Flu clinics.

Wellbeing day planned for 4th March 15 G Working for us pages of website revised, branded job descritptions in use for vacancies. Values based recrutiment questions used at interview

SO5 – Well led – to be an organisation that is well led Ref

Source

Action

5.1 Strategic objectives delivery plan

Demonstrate increase in market share due to repatriation of services 31.3.15

Paul Simpson

Larisa Wallis

5.2 Strategic objectives delivery plan

Develop recruitment plan, monitor delivery and report to workforce committee

Fiona Allsop

DCNs

Quarterly

Updated market share analysis for SASH for 2013-14 and the last six years including GP referral trends. Significant growth in volume in elective (+31%) and outpatient activity (+60%) since 2008/09 whilst maintaining our market share across the catchment area. Updated the Market Development Strategy. Arranged a training session for divisions on Dr Foster Hospital Market Mananagement module. 5 workstreams agreed with project plan against each of workstreams. Numbers to be finalised

RAG status Three new wards and Cardiology Angiography Suite (due to open in July 2015) will enable the Trust to repatriate currently outsourced elective activity. SASH regained chemotherapy activity from local GPs previously sent to other providers following the opening of St Luke's Unit (in conjunction with RSCH). The Trust has also initiated bowel cancer screening service.

5 workstreams still progressing and being monitored via PMO Business case for international recruitment to be developed in the new year

plan continuing 5.3 Strategic objectives delivery plan

Ensure 90% of staff have PDP and turnover reduces to 12% and report to workforce committee

Quarterly

Yvonne Parker

Janet Miller

5.4 Strategic objectives delivery plan

Implement new performance appraisal system

30.09.14

Yvonne Parker

Sally Knight

5.5 Strategic objectives delivery plan

Establish periodic 360/ multi source feedback for doctors appraisals

Quarterly

Des Holden

Adam Stacey-Clear

5.6 Strategic objectives delivery plan

Complete delivery of SaSH plus GE clinical leadership programme

Quarterly

Des Holden

5.7 Strategic objectives delivery plan

Complete delivery of Foresight board development programme

Quarterly

Gillian FrancisMusanu

5.8 Strategic objectives delivery plan

Undertake staff listening event

Quarterly

Yvonne Parker

5.9 Strategic objectives delivery plan

Audit governance systems and internal control mechanisms

Quality Account 5.10

Colin Pink

Quarterly

Gillian Francis Musanu

Colin Pink

Quarterly

Ian Mackenzie

Carol Dixon

New cleaning equipment Cleanliness

Quality strategy

Shift majority of cleaning to daytime rather than at night

72% of appraisals completed and turnover at 16% A

Pilot ongoing and extended to include managers with appraisals due in jan 2015

Complete and in place

The Trust has also initiated bowel cancer screening service.

3 Workstreams agreed, steering group agreed, devleoping plans for 2nd phase of project. Appraisals system updated and pilot commencing for Band 8's

3 workstreams agreed and steering group established. Developing plan for 2nd phase of the project. Appraisal system drawing to a close. Approximately 60 culture champions identified and initial training has been delivered

On plan

Programme of continued Board development now in place for 2015/16

All divisions have held listening events in Q1 which have shaped local staff survey action plans.

External re-fresh assessment by Deloitte completed. Trust scored 3.5. Action plan developed and being implemented

Initial work completed to review two categories of internal control. Positive internal audit of development of IBP and Board Governance processes

New cleaning equipment purchased and in place

Cleaning timetable reviewed and as much moved to the day as possible

PIEDW now live, Information team to get training from Cerner on additional functionality now availiable Jan 2015

G B

5.11 IT strategy

Replace data reporting tool with Cerner PIEDW software available through HSCIC

31.12.14

Paul Bostock

Anna Wickenden

PIEDW technically live as at 10th November. Testing to be completed before planned go-live 8th December

5.12 IT strategy

Commence roll out of e-prescribing

31.12.14

Ian Mackenzie

David Heller

Go live due 8 December on Bletchingly ward. ePMA is live on Capel Annex and will be assessed in late January. Roll out due to commence Spring of 2015 following business case Following the assessment a paper will be pulled together with sign off recommendations for roll out.

5.13 IT strategy

Upgrade of end-of-life Trust operating systems

Quarterly

Ian Mackenzie

Peter Hodgetts

Work underway and on-target and funded in 2014/15 capital programme

The projected completion date is projected to be 9th march 2015.

Formally agreed by CHIG to move to NHSmail; Email archiving pilot (part of the plan) to be installed 13/1/2015; procurement planned by 7/2/2015 if all successful. Project Board membership being considered now, expected to be setup by end of January 2015.

Identified in capital plan for 2015/16 5.14 IT strategy

Provide upgraded email solution

5.15 IT strategy

Complete Network Upgrade

Quarterly

Ian Mackenzie

Peter Hodgetts

5.16 Estate strategy

Deliver estates capital programme

Quarterly

Ian Mackenzie

Shaun Cunningham

Quarterly

Ian Mackenzie

Peter Hodgetts

Identified in capital plan for 2015/16

Engagement with Avaya underway for design of new Core network and introduction of replacement switches. Temporary firewall in place - engagement with supplier for permanent replacement underway. Weekly project Board meetings for larger schemes. Weekly Weekly project board meetings in place for larger schemes. capital update and progress meeting with Director, capital projects Weekly capital update and progress meetings with lead director, and operational managers. capital projects manager and operational manager. Monthly reporting to FWC. Monthly reporting to FWC in place

Safety & Quality Committee Tuesday 8th January 2014 11.00 - 13.00 AD77 Trust Headquarters, East Surrey Hospital Minutes of Meeting Present: Richard Shaw Alan McCarthy Yvette Robbins Pauline Lambert Paul Simpson Barbara Bray Sally Brittain Angela Stevenson Debbie Pullen Jonathan Parr Katharine Horner Colin Pink Ben Emly Kim Rayment Dipa Bhella

RS AM YR PL PS BB SB AS DP JP KH CP BE KR DB

Cathy White Edwina Andersson Ben Mearns

CW EA BM

Non-Executive Director (Chair) Chairman Deputy Chair, Non-Executive Director Non-Executive Director Chief Financial Officer Chief of Surgery Deputy Chief Nurse Deputy Chief Operating Officer Chief of WACH Clinical Governance Compliance Manager Patient Safety & Risk Lead Corporate Governance Manager Head of Performance Patient Safety & Risk Facilitator Information Governance & Security Manager Patient Experience Lead Head of Legal Services Consultant Physician Clinical Lead for Acute & Elderly Medicine

Apologies Des Holden, Fiona Allsop, Paul Bostock, Michael Wilson, Virach Phongsathorn, Karen Devanny, Victoria Daley Action 1

GENERAL BUSINESS 1.1. Chair welcomed everyone to the meeting and apologies were noted. 1.2. Minutes of the previous meeting The December meeting minutes where agreed as an accurate record with one change to page 1 it was noted that Pauline Lambert had sent her apologies. 1.3. Actions from previous meeting were discussed as follows C/F 11th August 2014 • All due items on the agenda for discussion. C/F 2nd October 2014 • Clinical leads to discuss whether changing clinician during operational ward moves is an advantage for both the patient and clinical team. To Feedback to SQC February 2015 C/F 6th November 2014 • All due items on the agenda for discussion. C/F 4th December 2014 th

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• •

Discharge information. The action was updated to clarify the output required by SQC which was assurance on the time of day that patients are discharged. All due items on the agenda for discussion.

COMMITTEE BUSINESS 1.2.1 Highlights from Executive Committee for Quality, Risk CP gave a verbal update: The committee discussed the number of overdue incident reviews and the number has reduced significantly. The meeting monitored QGAF actions and a number were closed at the December Board meeting. An update on the Claims and Litigation Report was given. Medicine presented a review of mortality and a stroke review. WACH have undertaken a review of urgent neonatal admissions and they presented the outcome and gave good assurance to the committee. They also gave good assurance around the NICE guidance on intrapartum care. Finally there was a presentation from Library Services on the presentation of data within the Trust and the use of SPC charts. 1.2.2 Highlights from CQRM BE summarised the main points of discussion. The committee reviewed the October performance data and discussed the ED performance as the target had not been met. Quality Summit letter submitted by RS, it was acknowledged it wasn’t possible to generate a response in time for the Board meeting but it was hoped that they would be in a position to respond in time for this meeting. Apologies from VD no direct response to RS. This will be followed up at CQRM in 2 weeks time. Short discussion on cancer, while the Trust is achieving the targets the discussion focused on whether there is anything that could be done better, particularly from a network wide perspective. The discussion also touched on the in-patient cancer survey. It was agreed that there would be a combined deep dive in February to review both issues and that the network would be invited to present their views on what the whole health system could do to improve. AM asked whether the CCG’s are meeting their commitments in respect of the operational pressures and the actions from the CQC. BE replied that West Sussex and Surrey cited the System Resilience Groups (SRG) as the place where the work is happening. PS further explained that the Trust are involved with three SRGs. There is a formal structure now established and each of the SRGs reports to the Chief Officers meetings although this has yet to happen. PS yet to see a report from SRG. CQRM also touched on work being undertaken by 20:20 who have a spectrum of projects of varying difficulty and impact. It was noted that the most complex of these projects would be those relating to capacity. th

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AM asked for clarification on the 20:20 and whether it was in a position to report yet and where it would report to. PS confirmed that the Trust had reached agreement with the community trusts on what 20:20 would cost and what it will do. The work hasn’t begun yet and therefore hasn’t started formally reporting yet. 1.3 Quality Summit update from CCG VD has e-mailed to say that Sussex will provide an update to the January Board. PS has requested that KD for Surrey does the same. PS reported that nothing was escalated to the Single Performance Conversation which was cancelled as a result.

PS reported that there was still progress to be made on the Emergency Tariff with the CCG’s. QUALITY PERFORMANCE 2.2 SQC Dashboard RS asked for a specific update on ED performance given the extensive coverage in the national press. AS noted that the dashboard for November reports 95.5% performance in ED. The Trust is now recovering well from a difficult two weeks. Although the attendance numbers have not been exceptionally high there have been an unprecedented proportion of ambulance transfers of very sick patients, leading to high numbers of admissions. The Trust currently has a high number of delayed transfers of care (currently 33) and a high number of patients who are medically fit for discharge. AS reported that the Trust has gone in to full formal escalation with the CCGs and Social Services, over the past two weeks the Trust has had twice daily conference calls to track patients through the system (to home, nursing homes or community hospitals). The Trust is currently using all escalation areas (endoscopy, day surgery and angiography day case unit) which has inevitably led to cancelation of elective activity. There are 80 medical outliers on surgical wards which will explain why some surgical procedures have had to be cancelled. The situation is now getting better. Patients are being cohorted at ED, there has been one example of patient whose handover took more than two hours but they had been assessed and were felt to be safe. AS felt that the Trust’s good relationship with the Ambulance Service has been key in minimising the impact. AS also reported that from a Patient Experience perspective the Trust has received a number of compliments from patients and carers throughout this period. AS also drew the meeting’s attention to the challenge being presented by the number of deaths being reported within the region. The South East and London have declared use of the Excessive Death Policy, this means that access to mortuaries is being reviewed and shared across the region. The situation has been made worse by the Christmas and New Year period when funeral homes were closed, therefore not taking bodies away from the hospital. Additional facilities have been put in place at Ashford and St Peters for Surrey. SASH has scoped and is preparing to install additional facilities should they be required. th

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RS asked whether this was due to an increase in deaths or the Christmas break. AS replied that this wonâ&#x20AC;&#x2122;t become clear for another couple of weeks until the data becomes available. PL asked for clarification on whether patients are appropriately attending ED. AS acknowledged that this was a difficult question to answer because all patients who attend will be appropriately treated, not always easy to know whether there would have been a more appropriate option within the community. The figures, so far, are not showing high levels of minor injuries. PS reported that the Trust will hold a debrief meeting week commencing 12th January to understand the data once the pressure is off the hospital. PS confirmed that there would be a report to the Board following the debrief meeting. AM observed that with extreme pressure on the wider healthcare system the Trust appears to be managing a high degree of risk. AM asked from a safety and quality view which was the greater risk; not being able to treat emergency patients optimally or cancellation of elective patients? He noted that for the first time cancer patients had been cancelled. He also noted that the volume of activity was having a significant impact on the resilience of staff. AS agreed that the Trust was managing a significant amount of risk and it was not easy to see how well the risk is being managed within the community. On a daily basis the risk is managed by the operational meetings. AS confirmed that the Trust is very thorough and careful about which patients are cancelled if it becomes necessary. The risk is balanced where possible for example angiography patients are being transferred to the Royal Brompton and St Georges for their procedures. However it was acknowledged that balancing the risk is an intensive process that requires a significant degree of micro-management. AS noted that there is a risk associated with the large number of medical outliers across the Trust. The Medical consultants are spread thin; this is being managed by a schedule of ward rounds across the Trust, increased numbers of registrars supporting the rounds and help from surgical juniors on the wards. Matrons are instrumental in flagging patients who may experience in getting reviews. Staffing is being managed from within the ops centre too. SB confirmed that the operational plans in place are robust and that the decision making process has been good. She felt that this would demonstrate good management. There was some discussion about whether the risk was being effectively shared with the CCGâ&#x20AC;&#x2122;s in view of evidence emerging that GP practices were not busy over the same period. However, it was agreed that at this stage this is intangible, but where the Trust did need immediate support was in the prompt discharge of the 33 DTCs. AS pointed out that this was one of the key functions of the SRGs and that input from Social Services has been limited since 19th December. PS confirmed that a major incident had not been declared and clarified that a major incident can only be declared by the Ambulance Service. The Execs th

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have agreed a protocol to manage an escalating situation under business continuity. AM asked where the risk best managed given that the out of hospital risk management appears to be minimal and where the main risk to the organisation - a sub-optimal service to emergency patients or the cancellation of elective patients? He also asked how much longer could the staff maintain this level of intensity. AS confirmed that there are risks in all areas, it is difficult to assess how that risk is being absorbed in the community but as the last step in the process it does fell like the Trust holds most of the risk. She confirmed that the situation was being micromanaged on a daily basis through the Ops Team meetings. Operations have been cancelled but the team is very thorough and careful in the process of identifying those cancellations. Angiography patients have been transferred up to the Brompton in London. Medical Consultants were challenged by the spread of their patients across the Trust but that this was being underpinned by extra registrars, planned schedules of visits and support from surgical juniors. Matrons have been pivotal in providing clinical feedback to the ops team in the timely management of patients through the system. SB confirmed that the right risk escalation processes were in place, that the decisions being made were good ones and that an overview of staffing was kept at all times. SB also noted the support of the Board. In terms of risk sharing it was noted that input from Social Services had been limited since 19th December 2014. The 33 DTCâ&#x20AC;&#x2122;s in the Trust was a tangible problem whereas admission avoidance was a more difficult issue to adequately assess in terms of effectiveness. One of the reasons why the SRG was set up was to facilitate the process of discharge. RS asked where this should be escalated through 20:20. PS confirmed that MW has sent correspondence to the Councils in West Sussex and Surrey regarding the escalation process in Social Care. RS summed up the discussion. SQC could take assurance from the actions being taken to manage a difficult set of pressures, but concerns remain that a higher level of risk is falling on the hospital as a result. 2.4 SQC report to the Audit Committee on Internal Controls Assurance CP introduced the paper. 12 months ago it was decided to document all the internal controls within the Trust. These were broken down into 8 different groups, Clinical Governance was the first group taken to AAC. This is the paper that summarises the internal controls in place. CP noted a mistake in the paper; section C7 which should read 2x4=8, amber. This would be updated before the paper was submitted to AAC. RS noted that this paper reflected the management assessment risk. RS felt that the paper reflected the concerns of SQC with regard to the approach to Clinical Audit, whether the right issues are being reviewed, completion of the programme and whether learning is implemented. th

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It was noted that the Internal Controls make sense, that Clinical Audit is very different from internal and external audit. It was felt that the Trust needed to improve the approach to non-national standard audits in terms of documenting the initial rationale for the audit and the subsequent action plans. PS noted that there were no actions against Incident Management which is rated amber. It was also noted that there are no actions regarding performance metrics to the Divisions from the Legal Department with regards to Claims and Litigation. AS noted that there was a requirement for Divisions to show evidence of learning as a result of litigation outcomes. Action: Additional actions to be added to the paper. To be submitted to the January Audit Committee. 2.5 Information Governance Update Position

DP noted that the report was originally presented at the Execs Committee in November. The Information Governance Toolkit has 45 requirements, for the Trust to achieve a satisfactory rating it must be satisfactory in all 45 (there are only two categories satisfactory or unsatisfactory). Performance data was submitted in October with a score of 68% which is a satisfactory rating. It is anticipated that for the final submission which is 31st March 2015 the Trust will achieve 71% with an overall satisfactory rating. One of the requirements in the toolkit is for all staff to received annual Information Governance training, 95% compliance is required for a satisfactory rating. The other requirements are policy based. All the Information Governance Policies have been recently reviewed and are all in date. It is anticipated that the Trust will meet the 95% target. Staff training is monitored by the Information Governance Steering Group and quarterly reports to the Exec Committee. There have been concerns about the timely training of new starters, this is being addressed by the inclusion of a Information Governance training pack within the Induction Pack sent to new starters before they start their employment. This started 1st January 2015. This will be monitored.

Subject access requests are monitored and any breaches reported on Datixweb. A permanent post has been created for Freedom of Information requests. There are also champions in each area who act as a first point of contact for requests to avoid breaches. PATIENT EXPERIENCE 3.1 Feedback on YCM Data April-May 2014 CW explained that there has been a drop in the response rate to YCM and FFT. It is a continual challenge to maximise the response rate. There is a target response rate for FFT in both A&E and inpatient with CQUIN payments attached so it is important in the next quarter that the targets are achieved. th

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The team have worked hard to identify how to maximise responses key points include; staff engagement, whether there is a process in clinical areas and an awareness in patients. A text reminder service will start for ED, inpatients, endoscopy, day surgery, angiography for all patients under 65 with a mobile phone number recorded on Cerner. Over 65â&#x20AC;&#x2122;s will be written to. Then a reminder will be texted to all mobile holders. This will subsequently be rolled out to Outpatients. It was noted that where feedback is given to staff engagement is better. In addition strong clinical leadership is beneficial. A patient experience improvement plan has been introduced. Ward matrons and managers are being asked to review the full range of patient experience data (FFT, YCM, PALs and complaints) and identify 3 examples of good practice and 3 areas they would like to improve, what they are going to do about it and then to sustain it. CW confirmed that figures are similar at other Trusts and that engagement is the biggest challenge nationally. Revalidation is another driver for consultant engagement (and nurse engagement from November 2015). RS felt that the actions described gave SQC assurance that the dip in figures was being addressed. YR suggested that MWâ&#x20AC;&#x2122;s letter to staff which is also printed in the paper could be an opportunity to raise the profile of giving feedback. 3.2 Process of reviewing and sharing learning from the National patient experience surveys The meeting noted that the schedule of national surveys is extremely welcome. It was agreed that a summary report on the outcome of these surveys and any issues or implications that SQC would find of interest. It would be a useful source of assurance for SQC.

Action: A&E survey to come the February Meeting SAFETY 4.1 Update on Claims / Litigation Annual Report 2013/14

EA summarised the paper. EA noted that the Legal Department would be contacting the Chiefs of Divisions to find out exactly what they would like in future legal reports, what the capability of Datixweb is and how this can be progressed. In addition they can drill down into the NHSLA database and provide more of a breakdown of the litigation cases and this will be provided in future quarterly reports. RS asked about the learning that can be shared from legal outcomes. EA confirmed that she would need to speak to the Chiefs first, given the limitations of Datixweb it is anticipated that the NHSLA database (which includes financial information) may be a better source of data. AS reiterated how important the learning is, notwithstanding the time that may have elapsed since the incident. BB felt that early notification of a claim th

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is essential for proper investigation and management. PL asked what the process was for validation of claims. EA explained that on receipt of a new clinical negligence claim, a disclosure request, permission is sought from the clinical to disclose the Health Records. A letter of claim will follow with the specific allegations, these are immediately sent to the relevant Consultant. PL asked how well the clinicians understand the intricacies of the claims process, EA confirmed that the Legal Department could provide training to clinicians. EA confirmed that clinicians are involved in Trust response to recommendations made in a PFD report. It was noted that PFD reports are rare and the recent report was the first in a long time. BB confirmed that Surgical Inquests are presented and discussed at the Surgical Governance meeting. AM asked how NHSLA is paid for. PS explained that an uplift has been included in the tariff consultation which recognises the increase in costs and has been applied similarly across a range of HRGs which will disadvantage organisations with a particular case mix. PS could not confirm whether SASH will be affected as the cost modelling has not yet been done. PS noted that the Trust will see a cost saving in the contribution to NHSLA which is due to the Trustâ&#x20AC;&#x2122;s quality performance. RS summarised that there is an important issue of the timeliness and method by which learning from litigation is extracted for the Divisions. It was agreed that process of learning from litigation needs some work yet. The steps that need to be taken are understood. 4.2 Update on Patient Safety Committee Task & Finish Group Denise Newman was not present to provide the update to be carried forward. 4.3 Year on Year moderate and major harm in falls - review and verbal update This paper was a response to the question posed at the last SQC about whether there had been a year on year increase in the number of falls with harm. SB explained that when presented as per 1,000 days the data shows a relatively static position which gives assurance, especially within the context of the Trust treating an increasing number of patients. RS confirmed that it was reassuring to see that the work undertaken to manage falls is having a positive impact. RS requested that the information be included in future update reports. PS asked whether it would be possible to look back by another 3 years at falls with harm per 1,000 bed days. BE confirmed it would, if the data exists. Action: Summary of falls per 1,000 bed days from 2010. Specific review of whether the new design of Capel Ward has an impact on

BE FF

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falls - specifically nurses sitting in bays and the new non-slip/bounce flooring. 4.4 Review of increase in major harm incidents in Q2 KH noted that the report had the wrong heading and should have read Increase in major/moderate harm incidents in Q2. KH presented the report and was able to give assurance that although a high number of incidents relating to clinical diagnosis had been reported these related to historical incidents and did not all occur within Q2. All but one of the incidents has been reported as a Serious Incidents and are being investigated through that process. KR confirmed that the decision to declare a serious incident is based on the national criteria. Each incident is evaluated based on the degree of harm caused and whether there is evidence of clinical mismanagement.

KR confirmed that a number of the incidents were brought to the attention of the Trust through the claims process. QUALITY 5.1 Best practice for an integrated stroke pathway from a clinician’s perspective. BM presented the SNAP data for the 3 months up to September 2014. The SNAP audit is collated by the Royal College of Physicians, covers all Trusts, all CCG’s use this data to benchmark the Trust’s performance in the stroke journey of patient coming into and out of the hospital. Key points from the presentation: • the Trust is now scoring a B in the audit which is an increase from C (A is seen as world class). • positive impact of changes in the provision of therapies • the Trust contributes well to the audit which gives positive assurance in the results • SASH is in Band A for scanning > 50% of scans within 1 hour • Median time from clock start to scan is 40 minutes. This is easier to achieve where the patient is flagged up prior to arrival in the hospital. Sometimes the delay is the decision to scan not access to the scanner. • Stroke unit is scored as a D, this is because access to the stroke unit within 4 hours is a challenge due to bed pressures and operational activity. The number of stroke beds has increased from 28 to 39 with the opening of • the Capel annexe. It is important that everyone in the Trust follows the fastback bed policy. • Although not all patients get admitted to the stroke unit within 4 hours there is a stroke nurse who will meet the patient and stay with them until they are admitted to an appropriate environment. The stroke nurse is available 24/7. Thrombolysis can happen anywhere. • The team choose the patients to thrombolyse carefully based on clinical need. Although there is a push nationally to thromobolyse patients it can be harmful (1:20 will have a significant harm event). • Currently recruiting a new stroke consultant in conjunction with Epsom and St Hellier to achieve 7 day ward rounds. Swallow screening and other therapy targets have increased significantly. th

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BM explained that the current winter pressures are preventing the team from fully achieving the admission of a patient to the stroke unit with 4 hours. The Medical Division have: • increased the number of stroke beds • reinforced the fastback policy through the organisation • to increase the size of the stroke service AS explained that the SNAP data measures the process not the outcome for the patient. This is the next step. BM clarified that the composite measures within the SNAP data are difficult to score high until all the individual targets are achieved. BM pointed out that the Trust does not have an early support discharge team. This has not been commissioned by the CCG. BB commented that commendable progress has been made and the SNAP data is key to being able to demonstrate this. 6

ANY OTHER BUSINESS None. DATE OF NEXT MEETING 5th February 2015 14.00 – 16.00 AD77

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